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COLLEGE  OF  PHYSICIANS 
•     AND   SURGEONS 


Reference  Library 

Given  by 


SAJOUS'S 

Analytical  Cyclopaedia 

OF 

Practical  Medicine 

BY 

CHARLES  E.  de  M.  SAJOUS  M.D. 

AND 

ONE   HUNDRED   ASSOCIATE   EDITORS 


iSSISTED  BY 


CORRESPONDING  EDITORS  COLLABORATORS 
AND  CORRESPONDENTS 


Illustrated  witb  €broino-CitDodrarb$  Engravings  ana  mm 


Second  Revised   Edition 


■\70LtJ3xrE:  I 


Philadelphia 

F.  A.  DAVIS  COMPANY  PUBLISHERS 

1903 


COPYRIGHT,  1902,  1903, 

BY 
F.  A.  DAVIS  COMPANY. 

I  Registered  at  Stationers'  Hall.  London,  Eng.^ 


Philadelphia.  Pa.,  U.S.  A.: 

The  Medical  Bulletin  Printing-house, 

1914-16  Cherry  Street. 


RESPECTFULLY    DEDICATED 

TO  THE 

AMERICAN  MEDICAL  PROFESSION 

AS  AN 

expression  of  devotion. 
The  Editor. 


Digitized  by  tine  Internet  Arciiive 

in  2010  witii  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/sajoussanalytic01sajo 


PREFACE. 


When,  recently,  the  first  issue  of  the  Monthly  Cyclopaedia  of  Practical 
Medicine,  a  journal  published  in  connection  with  the  present  work,  was  placed 
before  the  profession,  the  changes  which  the  Annual  had  undergone  were 
described.  Journals  in  pamphlet  form  being  seldom  preserved,  it  is  deemed 
advisable  to  repeat  in  these  pages  the  main  reasons  which  have  led  to  so  im- 
portant a  step. 

It  was  to  adequately  assist  the  general  practitioner  that  the  Annual 
OF  THE  Univeesal  Medical  SCIENCES  was  started.  Just  ten  years  ago  the 
first  series  of  five  volumes  appeared.  What  its  life-history  has  been  need 
hardly  be  told;  that  over  five  hundred  thousand  volumes  have  been  distrib- 
uted in  the  United  States  alone,  sufficiently  indicates  the  generous  reception 
accorded  it,  while  the  encouragement  given  the  editor,  especially  by  his  col- 
leagues of  the  medical  press,  can  but  be  recalled  with  emotion. 

The  last  ten  years,  however,  have  been  prolific  in  changes  on  every  side. 
The  intense  activity  displayed  in  all  departments  of  medicine,  the  multiplicity 
of  divisions  and  subdivisions  in  medical  nomenclature,  the  ever-increasing 
value  of  time  and  the  stringency  of  available  pecuniary  resources  have  greatly 
modified  the  circumstances  surrounding  a  physician's  existence  and  his  needs. 
Although  the  Annual  had  become  a  much  appreciated  work  of  reference  for 
authors  and  teachers,  the  general  practitioner,  for  whom  it  had  been  espe- 
cially created,  failed  to  find  in  its  columns  the  kind  of  assistance  he  required. 
Often  disappointed  because  every  disease,  or  subdivision  of  a  disease, — pa- 
thology, treatment,  etc., — could  not  be  reviewed  each  year,  owing  to  the  fact 
that  the  subjects  had  not  received  the  attention  of  writers,  he  condemned  the 
work  in  toto,  overlooking  the  origin  of  the  omission.  Again,  he  found  the 
work  too  voluminous  for  current  reading, — the  very  mass  of  progressive  work 
appalled  him! 

A  careful  analysis  of  the  whole  question  revealed  the  underlying  cause 
of  trouble, — namely,  that  articles  made  up  of  heterogeneous  excerpts  fail  to 
excite  interest  and,  as  a  result,  soon  fatigue  the  intellect  of  the  reader.  Wlien- 
ever  a  new  line  of  thought  is  introduced,  the  subject  modified  by  the  new 
point  adduced  must  be  recalled  and  former  propositions  tending  to  transform 
both  the  older  and  the  newer  conceptions  of  the  subject  must  be  simultane- 
ously considered  and,  as  it  were,  digested.  That  the  sum  of  intellectual  labor 
required,  if  the  progressive  feature  advanced  is  at  all  to  prove  profitable,  must 
be  arduous,  is  evident ;  that  such  labor  gradually  engenders  a  disinclination 
to  utilize  the  kind  of  literature  involving  it  is  a  conclusion  which  deductive 
reasoning  can  but  sustain.     Briefly,  the  Annual  had  made  for  itself  a  place 


among  writers,  teachers,  and  investigators,  but,  for  the  reason  given,  it  had 
not  satisfactorily  fulfilled  its  mission  among  family  physicians,  for  whose 
benefit  it  had  been  especially  planned. 

Overworked,  overburdened,  and  often  poorly  paid,  general  practitioners, 
especially  those  exercising  their  calling  in  country-districts,  share  but  little 
in  the  enjoyments  of  life.  Harassed,  ever  anxious,  their  moments  of  respite 
are  but  opportunities  for  Nature,  and,  in  enforcing  her  rights,  she  subdues 
functional  activity  to  insure  recuperation.  In  her  way,  therefore,  she  pre- 
pares their  powers  for  the  morrow  and  thereby  contributes  her  share  to  their 
beneficent  labors.  But,  we  have  seen,  scientific  progress  also  has  its  claims, 
and  the  sufferer  is  entitled  to  the  resources  of  medicine,  not  as  they  were, 
but  as  they  are.  The  duty  of  the  medical  editor,  therefore,  lies  between 
Nature's  requirements  as  regards  the  physician,  and  the  claims  of  justice  as 
regards  suffering  humanity.  Both,  it  was  thought,  could  be  subserved  by  pre- 
senting even  scientific  literature  in  an  attractive,  entertaining,  easily-under- 
stood form,  with  professional  dignity  as  a  constant  guide. 

These  general  principles  have  formed  the  basis  of  a  modified  work, 
which  is  now  placed  before  the  profession.  Instead  of  presenting  the  ex- 
cerpts from  the  year's  literature  arranged  in  order  under  a  general  head 
as  before,  each  disease — including  its  subdivisions:  "Etiology,"  "Pathology," 
"Treatment,"  etc. — is  described  in  extenso,  and  the  new  features  that  the  year 
has  brought  forth  are  inserted  in  their  respective  places  in  the  text.  In  this 
manner  the  reader  is  saved  all  fatiguing  study:  he  has  before  him  what  in 
the  older  work  was  left  to  his  memory. 

The  work,  when  completed,  will  present  all  the  general  diseases  described 
in  text-books  on  practical  subjects — medicine,  surgery,  therapeutics,  obstetrics, 
etc. — and,  inserted  in  their  logical  order  in  the  text,  all  the  progressive  features 
of  value  presented  during  the  last  decade.  This  will  remove  the  cause  of 
dissatisfaction  caused  by  the  absence  of  general  subjects  in  the  older  work. 
If  the  year  brings  forth  nothing  new  upon  any  particular  disease,  the  latter 
will,  at  least,  appear  as  it  was  when  last  studied,  whether  this  be  one,  two, 
five,  or  twenty  years  before.  The  general  arrangement  adopted  will  make  it 
possible  to  cover  the  entire  field  in  six  volumes.  As  may  be  seen  in  any 
medical  dictionary,  the  siibjects  treated  in  the  first  volume  represent  exactly 
one-sixth  of  the  whck. 

While  the  general  practitioner's  needs  will  thus  be  adequately  provided 
for,  authors  and  teachers  will  not  have  to  deplore  the  change.  Instead  of 
having  at  their  disposal  only  the  reviews  of  a  single  year,  as  before,  they  will 
have  those  of  practical  value  published  during  the  last  ten  years.  The  arti- 
cle of  "Abdominal  Injuries,"  for  instance,  contains  one  hundred  and  sixty 
article  excerpts  besides  the  general  text;  that  on  "Appendicitis,"  a  still  larger 
number.  Being  interpolated  in  the  text  and  controversially  arranged,  the 
abstracts  either  sustain  the  views  advanced  or  indicate  fields  as  yet  insuffi- 
ciently explored.  This  arrangement  necessarily  precludes  chronological  order; 
indeed,  no  attempt  has  been  made  to  treat  the  various  subjects  historically, 
the  aim  being  to  give  them  an  essentially  practical  form. 


So  great  an  amount  of  matter  from  diiferent  sources  would  seem  to  insure 
a  degree  of  confusion  tending  greatly  to  increase  the  reader's  labors.  This  is 
avoided  by  using  large  type  for  the  general  text — that  is  to  say,  the  description 
of  a  disease — and  small  type  for  the  excerpts  from  journals.  Either  may  thus 
be  read  separately.  If,  for  instance,  the  reader  desires  to  merely  review  the 
general  subject,  he  has  but  to  read  the  text  in  large  type;  if  he  wishes  to 
analyze  or  study  a  disease,  operative  procedure,  drug,  etc.,  in  which  he  is 
particularly  interested,  he  has  but  to  include  the  small-type  text  in  his  perusal 
of  the  article. 

So  complete  a  rearrangement  of  the  entire  text  could  hardly  be  success- 
fully carried  into  effect  unless  the  editor  could  take  part  in  the  work  of 
preparation.  He  therefore  concluded  that  it  would  be  best  to  have  the  ma- 
jority of  the  sections  prepared  under  his  immediate  supervision  and  to  submit 
them  to  the  members  of  the  associate  staff  for  revision  and  correction.  Each 
editor  enjoying  the  privilege  of  erasing,  changing,  or  adding  anything  he 
chose,  the  correctness  of  the  views  presented  was  thus  insured,  while  the 
innovations  could  be  satisfactorily  carried  into  effect.  How  carefully  the 
associate  editors  have  fulfilled  their  share  of  the  labor  can  be  judged  from 
the  character  of  the  several  articles  bearing  their  names.  The  sections 
which  have  been  prepared  in  toto  by  associates  are  those  on  "Addison's 
Disease,"  "Angina  Pectoris,"  "Astigmatism,"  "Actinomycosis,"  "Anthrax," 
"Acetonuria,"  "Albuminuria,"  "Alcohol,"  "Antipyrine,"  "Atropine,"  "Bella- 
donna," "Blepharitis,"  and  "Bright's  Disease."  As  may  be  seen,  the  members 
of  the  associate  staff  have  again  placed  the  editor  under  great  obligation,  and  he 
wishes  to  express  to  them  his  deep  gratitude.  Drs.  Witherstine  and  G.  Archie 
Stockwell,  of  Philadelphia,  and  Dr.  Arthur  Turner,  of  Paris,  have  in  other 
directions  contributed  to  facilitate  the  editor's  task  and  have  placed  him  under 
many  obligations. 

The  unsigned  articles  have  not  been  submitted  to  associates.  The  more 
important  ones,  such  as  "Acetanilid,"  "Animal  Extracts,"  etc.,  were  written  by 
the  editor,  while  the  others  were  prepared  under  his  immediate  supervision. 
The  editor  also  selected  the  abstracts  for  all  the  articles;  any  error  of  judg- 
ment on  that  score  must,  therefore,  be  ascribed  to  him  alone.  Only  the  ex- 
cerpts thought  to  convey  practical  information  have  been  incorporated;  but 
this  feature  of  the  work  will  be  given  further  development. 

The  classification  adopted  is,  to  a  certain  degree,  a  novel  one,  general  sub- 
jects alone  appearing  in  the  list.  In  other  words,  individual  symptomatic 
manifestations,  such  as  asthenopia,  aphonia,  bradycardia,  etc.,  have  not  been 
given  separate  sections,  but  have  been  considered  under  the  diseases  of  which 
they  form  part.  This  has  made  it  possible  to  save  considerable  space,  which 
has  been  utilized  for  the  elaboration  of  subjects  that  are  scantily  considered 
in  text-books,  notwithstanding  their  great  practical  importance.  "Abdominal 
Injuries,"  for  instance,  so  frequent  since  electric  tramways,  foot-ball  games, 
and  bicycling  have  come  upon  the  scene,  have  been  given  over  forty  pages, 
while  the  various  phases  of  "Alcoholism" — doubtless  the  greatest  scourge  of 
the  human   race — have   been   considered   in   an   equally   exhaustive   manner. 


As  to  remedies,  only  those  that  are  being  generally  utilized  in  a  manner  com- 
patible with  scientific  precision  and  in  accordance  with  professional  ethics 
have  been  incorporated.  The  list  includes  a  few  new  agents  which  seem  to 
merit  further  trial.  Obsolete  remedies  have  not  been  mentioned,  the  aim 
being  to  present  those  which  constitute  a  modern  physician's  armamentarium. 
Again,  only  the  diseases  in  which  the  remedies  mentioned  are  of  special  value 
have  been  alluded  to,  along  with  what  new  points  the  recent  literature  may 
have  afforded. 

To  facilitate  the  use  of  the  work,  the  subjects  have  been  arranged  in 
alphabetical  order,  the  references  being  given  in  full  at  the  end  of  each 
abstract.  The  index  and  reference  list,  which  occupied  so  much  room  in  the 
older  work,  could  thu";  be  dispensed  with. 

The  personal  commentations  contributed  during  the  last  ten  years  by  the 
associate  editors  have  been  introduced  when  applicable,  and  many  illustrious 
names — some  of  which  recall  departed  friends,  such  as  D.  Hayes  Agnew,  Ben- 
jamin Ward  Richardson,  Dujardin-Beaumetz,  J.  Lewis  Smith,  Joseph  O'Dwyer, 
and  others — are  thus  perpetuated  in  the  pages  of  the  work. 

In  the  1896  issue  of  the  Annual  the  following  statement  was  made: 
"The  hard-worked  practitioner  is  the  protector  of  a  correspondingly  great 
number  of  human  lives;  to  help  him,  therefore,  in  acquiring  practical  knowl- 
edge is  to  increase  his  fighting  force, — i.e.,  to  help  him  in  the  accomplishment 
of  his  duty — a  higher  one  than  any  other  allotted  to  man."  These  words  can 
be  repeated  to-day;  they  represent  the  foundation  of  the  new  Annual  and 
Analytical  CTCLOPiEDiA  of  Phactical  Medicine,  which  the  editor  respect- 
fully dedicates  to  the  American  Medical  Profession  as  an  expression  of  pro- 
found devotion. 

The  Editor. 
2043  Walnut  Steeet. 


STAFF  OF  ASSOCIATE  EDITORS. 


Ciis(  Hevistd  June  1,  W03.) 


J.  GEORGE  ADAMI,  JM.D., 

JIONTEEAL,  P.  Q. 


LEWIS  H.  ABLER,  JI.D., 

PHILADELPHIA,    PA. 


JAMES   M.  ANDERS,  M.D.,  LL.D., 

PHILADELPHIA,    PA. 


THOMAS  G.  ASHTOK,  M.D., 

PHILADELPHIA,   PA. 


A.  D.  BLACIvADER,  M.D., 

MONTREAL,  P.   Q. 


E.  D.  BO^s^DURAXT,  M.D., 

MOBILE,    ALA. 


DAVID  BOYAIRD,  M.D., 

^•EW  TOP.K  CITY. 


WILLIAM  BROWXIKG,  M.D., 

EEOOBXTJs",  X.  Y. 


WILLIAJM  T.  BULL,  M.D., 

NEW  TOBK  CITY. 


CHARLES  W.  BURR,  M.D., 

PHILADELPHIA,    PA. 


HEXRY  T.  BYFORD,  M.D., 

CHICAGO,  ILL. 


HENRY  W.  CATTELL,  M.D., 

PHILADELPHIA,   PA. 


AYILLIAil  B.  COLEY,  M.D., 

KEW  YOP.K  CITY. 


FLOYD  M.  CRAXDALL,  M.D., 

NEW  YORK  CITl'. 


ANDREW  F.  CURRIER,  M.D., 

NEW  YORK  CITY. 


ERNEST  W.  GUSHING,  M.D., 

BOSTON,   MASS. 


gwily:m  g.  da^t:s,  m.d., 

PHILADELPHLA,   PA. 


N.  S.  DA^aS,  M.D., 
CHICAGO,  ILL. 


AUGUSTUS  A.  ESHNER,  M.D., 

PHILADELPHIA,   PA. 


SIMON  FLEXNER,  M.D., 

PHILADELPHIA,   PA. 


LEONARD  FREEMAN,  M.D., 

DENVER,  COL. 


S.  G.  GANT,  M.D., 

NEW  YORK  CITY. 


J.  McFADDEN  GASTON,  M.D., 

ATLANTA,   GA. 


J.  McFADDEN  GASTON,  Jr.,  M.D., 

ATLANTA,   GA. 


E.  B.  GLEASON,  M.D., 

PHILADELPHIA,    PA. 


EGBERT  H.  GRANDIN,  M.D., 

NEW  YORK  CITY. 


J.  P.  CROZER  GRIFFITH,  M.D., 

PHILADELPHIA,   PA. 


C.  M.  HAY,  M.D., 

PHILADELPHIA,    PA. 


(ix) 


STAFF  OF  ASSOCIATE  EDITORS. 


FREDERICIK  P.  HENEY,  M.D., 

PHILADELPHIA,    PA. 


L.  EMMETT  HOLT,  M.D., 

NEW  TOEK  CITY. 


EDWARD  JACKSON,  M.D., 

DENVER,  COL. 


W.  W.  KEEN,  M.D., 

PHILADELPHIA,   PA. 


EDWARD  L.  KEYES.  Jp..,  il.D., 

NEW  TOEK  CITY. 


ELWOOD  R.  KIRBl^  M.D., 

PHILADELPHIA,    PA. 


L.  E.  LA  FETRA,  j\I.D., 

NEW  Y'OEK  CITY. 


ERNEST  LAPLACE,  :\I.D.,  LL.D., 

PHILADELPHIA,    PA. 


E.  LEPINE,  M.D., 

LYONS,  FEANCE. 


F.  LEVISON,  M.D., 

COPENHAGEN,  DENMAEK. 


A.  LUTAUD,  M.D., 

PARIS,  FRANCE. 


G.  FRANK  LYDSTON,  :M.D., 

CHICAGO,  ILL. 


F.  W.  MARLOW,  M.D., 

SYRACUSE,  N.   Y. 


SIMON  JSIARX,  M.D., 

NEW  YORK  CITY. 


ALEXANDER  McPHEDRAN,  il.D., 

TORONTO,    ONT. 


E.  E.  MONTGOMERY,  M.D., 

PHILADELPHIA,   PA. 


HOLGER  MYC4IND,  JI.D., 

COPENHAGEN,  DENIIAEK. 


W.  p.  NORTHRUP,  M.D., 

NEW  YORK  CITY. 


RUPERT  NORTON,  M.D., 

WASHINGTON,  D.   C. 


H.  OBERSTEINER,  M.D., 

VIENNA,  AUSTEIA. 


CHARLES  A.  OLIVER,  M.D., 

PHILADELPHIA,    PA. 


WILLIAM  OSLER,  M.D., 

BALTIMORE,   MD. 


LE\ATS  S.  PILCHER,  M.D., 

BROOKLY'N,  N.  Y. 


WILLIAM  CAMPBELL  POSEY,  M.D., 

PHILADELPHIA,    PA. 


W.  B.  PRITCHARD,  M.D., 

NEW  Y'OEK  CITY. 


JAMES  J.  PUTNAM,  M.D., 

BOSTON,  MASS. 


B.  ALEXANDER  RANDALL,  M.D., 

PHILADELPHIA,   PA. 


CLARENCE  C.  RICE,  M.D., 

NEW  YORK  CITY'. 


ALFRED  RUBINO,  M.D., 

NAPLES,  ITALY'. 


REGINALD  H.  SAYRE,  M.D., 

NEW  YORK  CITY. 


JACOB  E.  SCHADLE,  M.D., 

ST.   PAUL,   MINN. 


JOHN  B.  SHOBER,  M.D., 

PHILADELPHIA,    PA. 


J.  SOLIS-COHEN,  M.D., 

PHILADELPHIA,   PA. 


SOLOMON  SOLIS-COHEN,  M.D., 

PHILADELPHIA,    PA. 


STAFF  OF  ASSOCIATE  EDITORS. 


H.  W.  STELWAGON,  M.D., 

PHILADELPHIA,    PA. 

D.  D.  STEWART,  M.D., 

PHILADELPHIA,    PA. 

LE\\'IS  A.  STIMSON,  M.D., 

NEW  YORK  CITY. 

J.  EDWARD  STUBBERT,  M.D., 

LIBEETY,  N.  T. 

A.  E.  TAYLOR,  M.D., 

SAN  FKANCISCO,  CAL. 

J.  MADISON  TAYLOR,  M.D., 

PHILADELPHIA,    PA. 

M.  B.  TINKER,  M.D., 

PHILADELPHIA,    PA. 

CHARLES  S.  TURNBULL,  J\I.D., 

PHILADELPHIA,    PA. 


HERMAN  F.  VICKERY,  JI.D., 

BOSTON,  MASS. 

F.  E.  WAXHAM,  M.D., 

DENVER,  COL. 


J.  WILLIAM  WHITE,  M.D., 

PHILADELPHIA,    PA. 


JAMES  C.  WILSON,  M.D., 

PHILADELPHIA,   PA. 

C.  SUMNER  WITHERSTINE,  il.D., 

PHILADELPHIA,    PA. 

ALFRED  C.  WOOD,  M.D., 

PHILADELPHIA,   PA. 

WALTER  WYMAN,  M.D., 

WASHINGTON,  D.  C. 


TABLE  OF  CONTENTS. 

(Volume  I.) 


PAGE 

Abdomen,  Contusions  of 1 

Abdomen,  Injuries  of 1 

Abdomen,  Wounds  of 20 

Abdominal  Aorta,  Aneurism  of 329 

Abortion    38 

Abscess  60 

Abscess,  Acute  60 

Abscess,  Cold    65 

Abscess,  Tuberculous   65 

Absinthium   67 

Absinthium  Poisoning  68 

Acetanilid    68 

Acetanilid  Poisoning 70 

Acetic  Acid  74 

Acetic- Acid  Poisoning    75 

Acetone,  Excretion  of 76 

Acetone,  Tests  for 81 

Aoetonuria    76 

Aceto-ortho-toluide 85 

Acetj'lene 86 

Acetylene  Poisoning  86 

Acne    87 

Acne  Rosacea  96 

Aconite 102 

Aconite  Poisoning  103 

Aeonitine   107 

Aconitine  Poisoning  107 

Acromegaly  108 

Acromegaly,  Thyroid  Extract  in 385 

Actinomycosis 121 

Actol  131 

Addison's  Disease 132 

Addison's  Disease,  Suprarenal  Extract  in .  398 

Adenitis    147 

Adonis    160 

Adonis  Poisoning  161 

Agalactia   161 

Agaricin   164 

Agraphia    435 

Ainhum    165 

Airol    166 

Airol  Poisoning  166 

Alalia    434 


PAQB 

Albumin,  Tests  for 178 

Albuminuria   168 

Alcohol  183 

Alcohol  Poisoning  185 

Alcoholic  Neuritis  193 

Alcoholic  Paralysis  193 

Alcoholism     196 

Alexia  437 

Alkaloids    229 

Aloes  231 

Aloin     232 

Alopecia   233 

Alopecia  Areata 240 

Alum 249 

Aluminium    250 

Alumnol   251 

Amenorrhoea  253 

Amimia    435 

Ammonia   260 

Ammonia  Poisoning  261 

Ammonium    262 

Ammonium-Chloride  Poisoning 264 

Amj'lene  267 

Amylene-hydrate  268 

Amylene-hydrate  Poisoning 269 

Amyliform  271 

Amyl-valerianate 272 

Ansemia    272 

Anaemia,  Bone-marrow  in 409 

Ansemia,  Pernicious   279 

Antemia,  Pernicious,  Bone-marrow  in ...  .   409 

Analgen    294 

Anesin 295 

Aneurism   296 

Angina  Pectoris  342 

Anhaloniura  Lewinii  352 

Animal  Extracts    354 

Anorexia  Nervosa  416 

Anthrax   419 

Antipyrine  423 

Antipyrine  Poisoning  426 

Aortic  Aneurism   318 

Aphasia    434 

(xiii) 


TABLE  OF  CONTENTS. 


PAGE 

Aphemia     434 

Aphrosia    434 

Apiol  448 

Apooynum  Cannabinum 449 

Apomorphine    451 

Apomorpliine  Poisoning    452 

Appendicitis    455 

Appendicitis:    Relapsing  Form 492 

Apraxia    437 

Argonin    495 

Aristol    496 

Arrested  Growth,  Thyroid  Extract  in ...  .  363 

Arsenic   501 

Arsenic  Poisoning  506 

Arterio-venous  Aneurism   339 

Asthma     512 

Astigmatism   526 

Athetosis   532 

Atropine     536 

Atropine  Poisoning 540 

Auditory  Blindness  435 

Axillary  Aneurism    328 

Barium 547 

Belladonna     548 

Belladonna  Poisoning 549 

Benzoic  Acid  556 

Benzoin    558 

Beriberi    559 

Bismuth   571 

Bismuth  Poisoning   573 

Blepharadenitis    576 

Blepharitis     576 

Bone-marrow    407 

Boracic  Acid  580 

Borax 584 

Boroformate    250 

Borotannate    251 

Borotartrate  251 

Brachial  Aneurism   329 

Breast-pang    342 

Brain  Extract 415 

Bright's  Disease  586 

Bromide  of  Ethyl   622 

Bromides,  Poisoning  by 630 

Bromine  and  Its  Derivatives 622 

Bromism     631 

Bronchiectasis    633 

Bronchitis    640 

Buckthorn  (Cascara)    654 

Burns    654 

Cajuput-oil    669 

Calcium    670 


PAGE 

Camphor ' 672 

Cancer,  Thyroid  Extract  in 390 

Cannabis-Indica  Poisoning   679 

Cannabis  Indica  seu  Sativa 677 

Cantharides     682 

Cantharides  Poisoning 684 

Carotid  Aneurism  325 

Cascara     654 

Catalepsy     688 

Chautard's  Test  for  Acetone 82 

Chlorosis,  Bone-marrow  in 409 

Cirsoid  Aneurism 337 

Cold  Abscess  65 

Contusions  of  Abdomen 1 

Contusions  of  Intestine  4 

Contusions  of  Stomach  6 

Cretinism,  Thyroid  Extract  in 364 

Cysts,  Retention   576 

Delirium  Tremens   201 

Epilepsy,  Thyroid  Extract  in 375 

Exophthalmic  Goitre,  Splenic  Extract  in.  404 

Exophthalmic  Goitre,  Thymus  Extract  in.  392 

Exophthalmic  Goitre,  Thyroid  Extract  in.  375 

Fehr's  Test  for  Acetone 82 

Femoral  Aneurism   333 

Foot-drop  (see  also  Neuritis,  Multiple)  .  .  561 

Goitre,  Thymus  Extract  in 391 

Goitre,  Thyroid  Extract  in 377 

Gunning's  Test  for  Acetone S3 

Gunshot  Wounds  of  Abdomen 21,  35 

Heller's  Test  for  Albumin 179 

Heynsius's  Test  for  Albumin 179 

Hindenlang's  Test  for  Albumin 179 

Hodgkin's  Disease,  Bone-marrow  in 411 

Iliac  Aneurism  332 

Injuries  of  Abdomen 1 

Insanity,  Thyroid  Extract  in 379 

Intestines,  Contusions  of 4 

Johnson's  Test  for  Albumin 179 

Keloid,  Thyroid  Extract  in 375 

Lactation,  Thyroid  Extract  in 384 

Laparotomy  (see  also  Peritonitis;    Stom- 
ach,  Surgery   of) 29,  481 

Le  Nobel's  Test  for  Acetone 82 

Legal's  Test  for  Acetone 82 


TABLE  OF  CONTENTS. 


XV 


PAGE 

Leprosy,  Thyroid  Extract  in ...  , 375 

Leulcaemia,  Bone-marrow  in 410 

Lieben's  Iodoform  Test  for  Acetone 83 

Lungs,  Actinomycosis  of 124 

Lupus,  Tliyroid  Extract  in 374 

Macewen's  Method  in  Aneurism 312 

Malarial  Cachexia,  Bone-marrow  in 410 

Malerba's  Test  for  Acetone 84 

Mania  a  Potu  207 

McBurney's  Operation    4S2 

Mescal  Button   352 

Middle-Ear  Disorders,  Thyroid  Extract  in.  384 

Millen's  Test  for  Albumin 179 

Muscular  Atrophy,  Thyroid  Extract  in .  .   385 
Myxoedema,  Thyroid  Extract  in 382 

Nephritis   586 

Nerve  Extract   415 

Neurasthenia,  Suprarenal  Extract  in ...  .  401 

Neuritis,  Alcoholic   193 

Nitroeyanide  Test  for  Acetone 84 

Obesity,  Tliyroid  Extract  in 386 

Orehitic,  or  Testicular,  Extract 412 

Organic  Extracts  403 

Osseous  Deformities,  Bone-marrow  in.  .  .  .  411 

Ovarian  Extract   405 

Paralysis,  Alcoholic   193 

Paralysis  of  Diaphragm   (see  also  Diph- 
theria, Complications)   5fil 

Penzoldt's  Indigo  Test  for  Acetone 84 

Perchloride-of-Mercury  Test  for  Albumin.  179 

Pituitary  Extract  402 

Placenta,  Retention  of 41 

Poikilocytosis    (see    also    Stomacli,    Car- 
cinoma)        284 

Poisoning,  Absinthium    68 

Poisoning,  Acetanilid 70 

Poisoning,  Acetic  Acid 75 

Poisoning,  Acetylene   86 

Poisoning,  Aconite   103 

Poisoning,  Aconitine 107 

Poisoning,  Adonis   161 

Poisoning,  Airol  166 

Poisoning,  Alcohol    185 

Poisoning,  Ammonia    261 

Poisoning,  Ammonium  Chloride 264 

Poisoning,  Amylene-hydrate    269 

Poisoning,  Antipyrine 426 

Poisoning,  Apomorphine  452 

Poisoning,  Arsenic    506 

Poisoning,  Atropine    540 


,,    .  .  PAGE 

Poisoning,  Belladonna  549 

Poisoning,  Bismuth    573 

Poisoning,  Bromides  630 

Poisoning,  Cannabis  Indica   679 

Poisoning,  Cantharides   684 

Popliteal  Aneurism 335 

Psoriasis,  Thyroid  Extract  in 373 

Quantitative  Tests  for  Albumin 181 

Reynold's  Test  for  Acetone 83 

Rhinoscleroma    99 

Roberts's  Test  for  Albumin 179 

Rodent  Ulcer  (see  also  Camphor,  and 
Tumors  of  Eyelids) 76 

Splenectomy  (see  also  Spleen) 17 

Splenic  Extract 403 

Stenocardia  342 

Stomach,  Contusions  of 6 

Subclavian  Aneurism 327 

Suprarenal  Extract    394 

Syphilis,  Thyroid  E.xtract  in 387 

Syphilitic  Alopecia    240 

Tanret's  Test  for  Albumin 179 

Testicular  Extract    412 

Tests  for  Acetone 81 

Tests  for  Albumin  178 

Tetany,  Thyroid  Extract  in 387 

Thymus  Gland,  Extract  of 391 

Thyroid  Gland,  Extract  of 354 

Torticollis,  Thyroid  Extract  in 388 

Traumatic  Aneurism   336 

Tuberculous  Abscess 65 

Uterine  Disorders,  Thyroid  Extract  in.  . .   388 

Varicose  Aneurism    329 

Warm  Abscess    60 

Word-blindness  (see  also  Vascular  Dis- 
eases of  Brain) 437 

Word-deafness      (see     also     Tumors     of 

Brain;    Vascular  Diseases  of  Brain)  ..  .   436 
Wounds    of   Abdomen    Due    to    Military 

Firearms    35 

Wounds  of  Abdomen,  Non-penetrating.  .  .     20 

Wounds  of  Abdomen,  Penetrating 21 

Wrist-drop  (see  also  Lead  Encephalop- 
athy; Mercurial  Poisoning;  Neuritis, 
Multiple)    561 

Xanthoprotein  Test  for  Albumin 180 


Sajous's 
Analytical  Cyclopaedia  of  Practical 

Medicine. 


ABDOMEN,  INJURIES  OF  THE. 
Contusion. 

Symptoms.  —  The  symptoms  attend- 
ing a  contusion  of  the  abdomen,  whether 
caused  by  blows,  kicks,  spent  bullets,  the 
passage  of  heavy  bodies — such  as  ve- 
hicles— over  the  abdomen,  etc.,  are  not 
always  such  as  to  call  attention  to  the 
seriousness  of  the  lesion  present.  The 
gravest  abdominal  injuries  may  co-esist 
with  practically  no  external  or  general 
indication  of  mischief,  the  patient  walk- 
ing a  long  distance,  perhaps,  without  ex- 
periencing anything  more  than  slight 
local  pain  where  the  blow  had  been  re- 
ceived. 

Case  of  traumatic  rupture  of  the  small 
intestine  caused  by  a  very  slight  blow 
which  left  no  mark.  Extensive  peri- 
tonitis and  free  exudate  were  present  six 
hours  after  the  injury,  although  there 
was  almost  entire  absence  of  symptoms 
apart  from  cessation  of  peristalsis  and 
slight  vomiting.  J.  J.  Buchanan  (An- 
nals of  Surg.,  Nov.,  1900). 

From  observations  of  some  twenty 
cases  of  visceral  injury,  following  con- 
tusion of  the  abdomen,  verified  by  opera- 
tion or  autopsy,  the  most  prominent 
were  pain,  tenderness,  and  muscular 
rigidity,  and  likewise  the  most  reliable. 
The  deep-seated,  localized  pain  following 
injury,  especially  increased  by  pressure, 
and  accompanying  local  or  general  mus- 
cular rigidity,  is  one  of  the  most  con- 
stant  signs   of   intra-abdominal   injury. 

1—1 


The  association  of  these  three  symptoms 
is  almost  pathognomonic  of  abdominal 
irritation.  Pain,  however,  is  often  pres- 
ent, with  tenderness,  in  injuries  limited 
to  the  abdominal  wall;  but  in  these  in- 
stances muscular  rigidity  is  generally 
absent.  In  the  absence  of  subcutaneous 
pain  localized  tenderness  with  rigidity 
is  strongly  suggestive  of  visceral  in- 
jury. Of  the  three  symptoms,  muscular 
rigidity  is  the  most  reliable,  and  some- 
times the  only  sign.  In  the  absence  of 
other  diseased  conditions  spasm  of  one 
or  more  of  the  abdominal  muscles  fol- 
lowing the  traumatism  may  be  looked 
upon  as  Nature's  effort  to  protect  an 
injured  organ  from  further  irritation. 
Vomiting  is  a  symptom  often  present, 
but  not  always  an  accompaniment  of 
severe  visceral  injury.  It  is  commonly 
present  with  involvement  of  the  stomach 
and  upper  part  of  the  intestinal  tube, 
and  with  injuries  resulting  in  severe 
shock.  The  signs  of  free  fluid  in  the 
abdominal  cavity  are  very  suggestive. 
C4.  E.  Brewer  (Annals  of  Surgery,  Feb., 
1903). 

The  abdominal  walls  may  be  but 
slightly  injured;  but,  again,  the  lesions 
may  consist  of  extensive  extravasations 
of  blood  between  the  layers,  or  sufficient 
laceration  of  the  muscular  and  other  tis- 
sues to  give  rise  to  more  or  less  local 
sloughing.  Such  lesions  of  the  abdom- 
inal wall,  however,  are  not  always  ac- 
companied by  injury  of  the  abdominal 
organs. 


ABDOMEN.     CONTUSION.     SYMPTOMS. 


A    trifling    superficial    injury    of    tire 
abdominal  wall  may  be  associated  with 
serious  internal  lesions,  owing  to  the  re- 
sistance offered  by  the  abdominal  walls 
and  the  fragility  of  the  abdominal  or- 
gans.    The  external  appearances,  there- 
fore, should  not  be  taken  as  a  criterion. 
Narrow  bodies,  the  action  of  which  is 
exerted    on    a    small    area,    reach    more 
deeply  by  overcoming  resistance  of  the 
abdominal    parieties    more    easily    than 
larger    bodies.      Resistance    varies    with 
the   age,  state   of  obesity,   and   state   of 
relaxation  or  contraction  of  the  muscles. 
The  direction  of  the  blow  is  of  impor- 
tance.     If   perpendicular   to    the    deeper 
structures,    it    is    most   harmful;     when 
parallel,    it    tends    to    glide    oiT;     when 
obliqus,  the  force  is  modified.     Demons 
(Brit.  Med.  Jour.,  Nov.  27,  '97). 

Case  of  young  man  riding  bicycle  when 
he  was  struck  in  upper  part  of  abdomen 
by  end-pole  of  an  express-cart  coming  in 
opposite  direction.  He  was  thrown  from 
wheel,  but  recovered  himself  soon.  Only 
symptom  slight  pain  and  tenderness  at 
seat  of  injury.  Three  hours  later  general 
abdominal  pain  and  tenderness,  steadily 
increasing.  Temperature  rose  quickly 
five  hours  after  injury.  Abdomen  was 
opened:  in  first  eight  inches  of  small 
intestine  drawn  out  of  wound  two  rents 
encountered,  the  larger  was  complete 
and  involved  half-circumference  of  gut. 
Smaller  one  partial,  involving  peritoneal 
covering  and  part  of  muscular  coat  only. 
Beginning  peritonitis  present.  No  ex- 
travasation of  intestinal  contents.  No 
evidence  of  hasmorrhage  of  importance. 
Five  inches  of  intestine,  including  in  it 
both  rents,  resected,  and  bowel  sutured. 
Recovery  complete  on  twenty-fourth  day. 
Francis  S.  Watson  (Boston  Med.  and 
Surg.  Jour.,  Feb.  10,  '98). 

A  severe  blow  in  the  abdomen  is  likely 
to  occasion  either  haemorrhage  or  per- 
foration. In  haemorrhage  the  pulse  grows 
softer,  while  with  perforation  and  ex- 
travasation the  pulse  hardens.  Turner 
(Lancet,  May  5,  1900). 

In  collapse  or  death  from  blows  upon 
the  epigastrium  the  solar  plexus  may  be 
disregarded   as   a   factor;     the   cause   of 


collapse  or  death  is  the  mechanical  vio- 
lence   exerted    upon    the    heart-muscle 
or    its   nerve-mechanism.      G.    W.    Crile 
(Phila.  Med.  Jour.,  Mar.  31,  1900). 
In    the    majority    of    cases,    however, 
severe  contusions  of  the  abdominal  wall, 
whether  the  deep  organs  are  involved  or 
not,  are  followed  by  agonizing  pain  in 
the   region   of   the   injury,   restlessness, 
nausea  or  vomiting,  marked  prostration 
(indicated  by  a  small,  rapid,  and  irreg- 
ular pulse),  pallor  (sometimes  attaining 
lividity),  cold  sweats,  rigidity  of  the  ab- 
dominal  wall,   meteorisni,   anxiety,   and 
fear  of  a  fatal  issue. 

Diffused  rigidity  of  the  abdominal  wall 
in  a  case  of  contusion  of  this  region, 
even  in  the  absence  of  any  other  serious 
symptom,  is  a  decided  indication  for  im- 
mediate laparotomy,  while  the  absence 
of  contracture,  whatever  may  be  the  ex- 
tent and  gravity  of  the  associated  symp- 
toms, contra-indicates  surgical  interven- 
tion. Of  10  cases  in  which,  owing  to  the 
presence  of  this  symptom,  laparotomy 
was  performed,  this  treatment  proved 
successful  in  9.  Of  17  cases  of  severe 
abdominal  contusion  in  which  no  opera- 
tive treatment  was  applied  in  conse- 
quence of  the  absence  of  rigidity,  all 
ended  in  recovery.  Hartmann  (Bull,  et 
Mem.  de  la  Soc.  de  Chir.,  Mar.  12,  1901). 

All  these  symptoms  bear  the  imprint 
of  a  severe  nervous  commotion,  and,  if 
the  extensive  distribution  of  the  sympa- 
thetic nervous  system  in  the  abdominal 
cavity  is  borne  in  mind,  the  fact  will 
become  evident  that  symptoms  usually 
witnessed  immediately  after  the  receipt 
of  the  injury  are  due  mainly  to  the  in- 
fluence of  the  concussion  upon  the  sym- 
pathetic supply.  Sudden  death  has  been 
known  to  follow  a  violent  blow,  espe- 
cially when  received  in  the  region  of  the 
solar  plexus. 

The  pain  varies  according  to  the  loca- 
tion of  the  traumatism  and  the  sensitive- 
ness of  the  patient.  Very  severe  at  first, 
it  usually  becomes  less  marked  after  a 


ABDOMEN.     CONTUSION.     SYMPTOMS. 


few  hours.  It  is  greatly  influenced  by 
shock,  profound  prostration  reducing  its 
intensity  by  reducing  sensation.  Great 
restlessness  usually  accompanies  abdomi- 
nal pain  after  injuries,  as  well  as  during 
other  diseases,  such  as  appendicitis, 
when  the  suffering  is  due  to  a  localized 
trouble.  The  pain  may  be  radiated  in 
various  directions, — the  shoulder,  the 
umbilicus,  the  left  axilla,  the  testicles, 
etc., — according  to  the  site  of  the  pri- 
mary lesion.  Local  tenderness  is  usually 
marked  over  the  site  of  the  traumatism. 
The  vomiting  varies  greatly  in  inten- 
sity from  mere  nausea  to  the  most  vio- 
lent expulsive  efforts,  which  are  liable, 
by  the  strain  upon  the  abdominal  organs, 
to  suddenly  increase  the  extent  of  the 
lesions.  The  vomited  matter  sometimes 
contains  blood,  especially  if  the  tapper 
portion  of  the  digestive  tract  is  involved 
in  the  injury.  Constant  and  persistent 
vomiting  tends  to  indicate  a  contusion 
accompanied  by  visceral  lesions. 

In    simple    cases    the   vomiting    is   re- 
peated but  two  or  three  times.     Wlien 
the  intestine  is  ruptured  the  vomiting  is 
persistent  and  intractable  and  liver-dull- 
ness is  absent.     Berndt    (Deutsche  Zeit. 
f.  Chir.,  vol.  xxxix,  p.  516). 
The  degree  of  shock  depends  upon  the 
nature  and  extent  of  the  injury  and  es- 
pecially upon  the  amount  of  blood  lost. 
When   the    signs   of   collapse   gradually 
become  more  marked,  internal  haemor- 
rhage from  rupture  of  one  or  more  of 
the  visQera  is  to  be  feared. 

The  pulse,  usually  rapid  and  weak  at 
first,  gradually  becomes  stronger  and 
slower  if  a  favorable  reaction  is  about 
to  take  place.  If,  on  the  contrary,  an 
unfavorable  course  is  being  taken  and 
some  complication  is  to  occur,  its  rapid- 
ity and  tension  may  become  increased. 
Irregularity  is  not  a  favorable  indication 
if  it  persists. 

The  temperature  is  independent  of  the 


pulse,  except  when  a  favorable  reaction 
is  taking  place,  when  it  may  return  to 
the  normal  line  after  having  gone  be- 
yond or  below  it.  The  usual  belief  that 
a  subnormal  temperature  always  follows 
internal  hemorrhage  is  fallacious;  for  it 
may  also  be  raised.  The  temperature, 
therefore,  is  of  no  value  as  a  guide. 

It  is  generally  believed  that  sub-' 
normal  temperature  is  always  present 
when  there  is  intraperitoneal  haemor- 
rhage. Cases  showing  that  there  may 
be,  on  the  contrary,  a  marked  elevation 
of  temperature.  Eeynier  and  Quenu 
(See.   de  Chir.,  Dec,   '95). 

Case  in  which  there  was  an  elevation 
of  temperature  of  3  V=°  F.  five  hours  after 
receipt  of  injury.  Vautrin  (La  Med. 
Mod.,  Feb.  15,  '96). 

In   abdominal    injuries    due    to    blunt 
force  the  symptoms  are  referable  to  the 
abdominal    wall    and    cavity,    or    both. 
Pain  may  be  severe  or  slight.     As  an 
early  symptom  vomiting  is  constant,  dis- 
tension may  be  slow  or  rapid,  rigidity 
develops  later,  shock  may  or  may  not  be 
present.    The  temperature  and  pulse,  par- 
ticularly  the   latter,   are    considered    of 
great  importance.    Opium,  even  in  small 
doses,  renders  the  diagnosis  of  such  in- 
juries difficult,  and  should  never  be  ad- 
ministered   early.      After   an   abdominal 
injury,   if  there   is  tenderness,   accelera- 
tion of  the  pulse  tending  to  increase  ever 
so  slightly,  together  with  abdominal  dis- 
tension and  a  rise  in  temperature,   the 
diagnosis  of  a  grave  injury  is  made  abso- 
lute.    In  most  eases  but  a  few  hours  of 
dose  observation  are  required  to  estab- 
lish the  diagnosis.    In  such  eases  explora- 
tory laparotomy  should  be  performed  at 
once  unless  the  condition  is  so  desperate 
that    anesthesia    means    certain    death. 
E.  S.  Fowler  (N.  Y.  Med.  Jour.,  Aug.  19, 
'99). 
Hfematemesis  may  assist  in  establish- 
ing the  diagnosis  of  lesion  in  the  stom- 
ach or  the  upper  portion  of  the  intestinal 
tract,  while  the  presence   of  blood  in 
the  stools  may  do  the  same  as  regards 
lesions  of  the  intestines  as  a  whole,  in- 
cluding the  colon.     But,  in  itself,  this 


ABDOMEN.     CONTUSION.    DIAGNOSIS. 


symptom  is,  by  no  means,  characteristic, 
since  a  violent  strain  may  cause  sudden 
engorgement  of  pharyngeal,  gastric,  rec- 
tal, or  hsemorrhoidal  vessels  and  then, 
several  days  after  the  accident,  blood- 
rupture  ensue.  Even  when  present, 
streaks  in  vomited  matter  or  stools  are 
not  always  indicative  of  an  alarming 
condition. 

Blood  in  the  urine  is  a  more  reliable 
sign  of  lesion  in  the  urinary  tract,  espe- 
cially the  kidney  and  bladder.  Anuria 
is  also  indicative  of  lesions  in  these  or- 
gans; but,  as  shock  frequently  arrests 
the  flow  of  urine,  it  is  only  valuable  as 
a  symptom  after  all  symptoms  of  shock 
have  passed. 

Haemorrhage  into  the  orbits  and  from 
the  ears  are  occasionally  met  with  when 
the  concussion  has  been  very  severe. 
This  symptom  does  not  necessarily  in- 
dicate that  the  injury  is  an  unusually 
dangerous  one. 

A  few  hours  after  the  accident  the 
pain  usually  becomes  reduced;  the  pa- 
tient may  be  more  quiet  and,  perhaps, 
somnolent,  although  the  pulse  remains 
in  its  former  condition.  This  period 
lasts  between  twelve  and  twenty-four 
hours.  If  at  the  end  of  this  time  there 
be  no  complication,  a  visceral  lesion  is 
probably  not  present.  If,  on  the  con- 
trary, the  symptoms  gradually  increase 
in  intensity,  the  likelihood  of  grave  in- 
jury is  very  great. 

In  the  light  of  present  knowledge, 
however,  the  practitioner  should  not  de- 
lay active  procedures  until  the  patient's 
life  becomes  compromised  by  permitting 
the  mechanical  injury  produced  to  start 
an  infectious  process,  when  the  manner 
in  which  the  injury  was  inflicted  and  the 
force  applied  tend  to  suggest  serious  in- 
ternal lesion. 

Diagnosis. — The  diagnosis  should  pri- 
marily be  based  upon  the  history  of  the 


accident,  the  manner  in  which  the  in- 
jury occurred,  the  shape  of  the  body,  or 
bodies,  by  means  of  which  the  trauma- 
tism was  inflicted,  and  the  degree  of  per- 
cussive force  applied,  and,  secondarily, 
upon  the  symptoms  present. 

Lesions  of  the  Intestinal  Tract. — Va- 
rious theories  have  been  advanced  as  to 
the  manner  in  which  rupture  of  the 
intestine  is  brought  about,  but  experi- 
ments have  shown  that  squeeziiig  of  the 
gut  between  the  compressed  abdominal 
wall  and  the  vertebral  column  is  the 
main  mechanical  factor  brought  into 
action.  Crushing  against  the  ilium  is 
rarely  produced.  Another,  although 
rare,  cause  of  rupture  is  the  presence,  in 
the  intestinal  tract,  of  liquid  or  semi- 
liquid  material,  the  sudden  circum- 
scribed pressure  exerted  upon  the  gut 
causing  it  to  burst,  through  overdisten- 
sion. The  small  intestine  is  the  seat 
of  lesion  in  75  per  cent,  of  the  cases  of 
rupture  in  the  course  of  the  intestinal 
canal.  Hence  the  importance  of  care- 
fully ascertaining  in  each  case  the  direc- 
tion from  which  the  percussive  force 
came,  the  intensity  of  that  force,  and  the 
relative  position  of  the  organs  between 
the  site  of  pressure  and  the  spinal 
column. 

The  character  of  the  force  and  th& 
mode  of  its  application  always  appear 
to  be  of  much  value  as  a  help  to  diag- 
nosis in  most  cases  of  intestinal  injury, 
for  it  would  seem  that  where  the  force 
is  of  diffused  rather  than  of  a  local- 
ized character  the  injury  is  more  likely 
to  be  extensive  or  even  double.  Thus, 
when  a  human  being  is  run  over,  the 
wheel  of  a  vehicle  passing  either  over  the 
abdomen  or  the  back  with  the  abdomen 
downward;  when  he  falls  from  a  height 
upon  a  plank  or  beam;  is  trodden  on  by 
a  horse;  or  is  crushed  between  two 
obtuse  bodies,  it  is  most  probable  that 
either  a  solid  viscus  has  been  lacerated 
or  that  some  portion  of  the  small  intes- 
tine has  been  torn  in  one  or  more  places. 


ABDOMEN.     CONTUSION.    DIAGNOSIS. 


Thomas  Bryant  (London  Lancet,  Dec.  7, 
'95). 

Seven  cases  of  severe  contusions  of 
the  abdomen,  with  intestinal  perfora- 
tion. The  seat  of  perforation  is,  in  the 
majority  of  cases,  in  the  small  intestine, 
and  successively  in  order  of  frequency 
come  large  intestine,  stomach,  and  duo- 
denum. Physical  signs  are  tympany  in 
the  epigastrium  and  an  area  of  dullness 
in  the  lower  portion  of  the  bowel. 
Adolph  Schmitt  (Munch,  med.  Woch., 
July  12,  '98). 

Case  of  a  boy,  aged  16  j'ears,  who 
had  been  kicked  in  the  abdomen  by  a 
horse,  but  who  presented  no  sign  of  ex- 
ternal injury.  There  was  vomiting  im- 
mediately after  the  accident,  and  ex- 
amination showed  that  the  abdominal 
walls  moved  in  respiration,  although  not 
quite  freely;  no  tenderness  in  any  par- 
ticular spot  on  light  pressure;  dullness 
on  percussion  in  the  hypogastrium  and 
flanks,  in  the  latter  situation  changing 
with  the  position  of  the  body.  Urine 
was  voided  without  difficulty.  The 
pulse  was  116,  and  the  patient  suffered 
from  shock.  He  was  put  to  bed  at 
once,  and  an  effort  made  to  relieve  the 
shock.  Two  days  later  his  condition 
suddenly  became  much  worse:  he  went 
into  collapse  and  died  a  few  hours  later. 
The  autopsy  showed  several  pints  of 
bloody  fluid  in  the  peritoneal  cavity  and 
a  tear  in  the  jejunum  near  its  com- 
mencement, close  to  the  spine,  about 
one  and  one-half  inches  long,  in  the 
longitudinal  axis  of  the  bowel,  at  its 
free  border.  Livingston  (Brit.  Med. 
Jour.,  Mar.  1,  1902). 

Another  factor  of  importance  in  es- 
tablishing a  diagnosis  is  the  size  of  the 
instrument  causing  the  injury.  Lesions 
of  the  digestive  canal,  for  instance,  are 
usually  the  result  of  violent  and  sudden 
percussion  produced  by  a  body  over  a 
limited  surface  of  the  abdominal  wall. 

The  predisposing  factors  are  the  pres- 
ence of  solid,  semisolid,  or  fluid  matter 
in  the  hollow  viseera;  leanness  of  the 
individual,  and  intestinal  adhesions. 

Any  of  the  above  accidental  causes  of 


injury  being  fulfilled,  rupture  of  some 
portion  of  the  gastro-intestinal  tract  is 
likelj',  especially  if  there  is  loss  of  con- 
sciousness at  the  time  of  the  accident, 
followed  by  collapse,  severe  pain,  a  rapid 
and  weak  pulse,  vomiting,  tympanites 
due  to  the  escape  of  intestinal  gas  into 
the  abdominal  cavity,  and  tenderness  and 
rigidity  of  the  abdominal  walls.  Such 
a  diagnosis  is  further  strengthened  by 
hasmatemesis  or  bloody  stools,  the  former 
tending  to  indicate  a  lesion  of  the  stom- 
ach. Death  occurs  in  96  per  cent,  of 
such  cases  if  unoperated. 

Two  signs  which  enable  the  physician 
to  diagnose  the  occurrence  of  intestinal 
perforation  before  peritonitis  has  had 
time  to  manifest  itself:  first,  distinctness 
of  the  murmurs  of  the  heart  and  respi- 
ration during  auscultation  of  the  abdo- 
men,— due  to  the  presence  of  intestinal 
gases  in  the  peritoneal  cavity.  Second, 
change  in  the  pulse^,  which,  at  the 
moment  of  perforation,  becomes  accel- 
erated, to  slacken  some  hours  later, — due 
to  the  absorption  of  putrid  gases  acting 
as  cardiac  poison.  Gluzinski  (Sem. 
Med.,  Nov.  6,  '95). 

A  ruptured  intestine  is  probably  pres- 
ent, though  this  is  not  certain,  when, 
after  a  diffuse  injury  to  the  abdomen  or 
a  severe  local  injury  as  the  immediate 
i-esult  of  the  accident^  there  is  little  col- 
lapse, and  where  vomiting  soon  becomes 
a  prominent  and  persistent  symptom, 
with  lasting  local  pain  and  great  thirst, 
with  or  without  abdominal  enlargement. 
Nineteen  cases  of  rupture  of  the  intes- 
tine adduced  confirm  the  truth  of  this 
statement.  Bryant  (London  Lancet, 
Jan.  11,  '96). 

After  contusions  and  wounds  of  ab- 
domen contraction  of  the  muscles  of  ab- 
dominal wall  indicates  certainly  visceral 
lesions.  Out  of  ten  cases  of  serious  con- 
tusion it  was  present  seven  times,  and 
surgical  intervention  resulted  in  the  dis- 
covery in  each  case  of  grave  visceral 
lesions.  M.  Hartmann  (Jour,  des  Prat., 
Oct.  29,  '98). 

Two  cases  of  rupture  of  colon.  The 
indications  for  exploration  are  the  nature 


6 


ABDOMEN.     CONTUSION.     DIAGNOSIS. 


and  history  of  the  injury,  frequent  and 
early    vomiting,    early    development    of 
rigidity  of  the  abdominal  walls,  local  ten- 
derness, and  impairment  of  resonance  in 
the  right  iliac   region;     the   absence   of 
definite   signs  of  injury  to  the   urinary 
bladder  or  solid  viscera,  combined  with 
the   evidence    of    serious    injury,    shock, 
pain,  rising  pulse,  general  pallor  and  per- 
spiration.    The  special  signs — as  cellular 
emphysema,  localizing  the  injury  to  the 
uncovered  portions  of  the  duodenum  and 
colon,  or  possibly  free  gas  in  the  peri- 
toneal   cavity  —  may    be   present.      The 
presence   of  any   of   these   signs  with   a 
rising  pulse  above  100  will  form  indica- 
tions for  abdominal  exploration.     G.  H. 
Makins  (Annals  of  Surgery,  Aug.,  '99). 
Lesions  of  the  Stomach. — Blows  seldom 
cause  rupture  of  tlie  stomach,  the  elas- 
ticity of  the  organ,  even  when  contain- 
ing liquid  or  semiliquid  material,  being 
such  as  to  cause  it  to  escape  injury  under 
sudden  impact  or  great  pressure.     It  is 
also   protected   by   the   lower   ribs,    the 
liver,  and  the  intestines.     Nevertheless, 
this   organ   is   occasionally   involved   in 
traumatism    affecting    other    abdominal 
viscera.     In  the  majority  of  cases  the 
rent  is  found  near  the  pyloric  orifice,  but 
the  greater  curvature  may  be  the  seat 
of  the  lesion,  while  the  entire  organ  is 
occasionally  torn  from  end  to  end.     In 
the  latter  case,  however,  death  ensues 
almost    immediately    in    practically    all 
cases.      Pressure    during   lavage   of   the 
stomach   may   also    cause   laceration    of 
the  mucous  membrane. 

Case  of  a  man  who  died  in  coma  after 
several  washings  of  the  stomach  for 
opium  poisoning.  At  the  necropsy  sev- 
eral rents  of  the  mucosa  were  found. 
Conclusion  that  the  presence  of  the  fluid 
was  the  cause  of  the  injury,  by  pressure. 
Key-Aberg  (Deutsche  med.  Zeit.,  Apr. 
28,  '92). 

In  the  case  of  incomplete  tears  there 
may  be  hsematemesis  and  severe  localized 
pain  resembling  that  of  gastric  ulcer, — 
gnawing  and  burning  in  character.    This 


is  followed  by  localized  inflammation 
with  tendency  to  the  formation  of  adhe- 
sions. Hsemorrhage  between  the  coats  of 
the  stomach  may  also  occur  in  incom- 
plete tears,  a  cyst-like  pocket  being 
formed. 

Violent  pressure  upon  the  stomach 
may  cause  it  to  be  crushed  against  the 
spinal  column,  and  the  mucous  surfaces 
be  lacerated  by  interpressure  of  the  an- 
terior and  posterior  walls  of  the  organ. 
In  such  a  case  a  marked  lesion  neces- 
sarily follows,  giving  rise  to  copious 
liEematemesis. 

Case  of  a  boy  who  was  caught  between 
two   freight-cars.      Shock    and   vomiting 
of  blood,  but  no  external  injury.    Twelve 
hours   after    the    accident    the    abdomen 
opened    and   a    slight   laceration    in   the 
spleen  sutured.     No  other  injury  found. 
The  autopsy  showed  two  ruptures  of  the 
mucous  membrane  of  the  stomach, — one 
of  the  anterior  wall  about  its  middle  and 
the  other  opposite  to  it  in  the  posterior 
Avail,  the  mucous  membrane  alone  being 
stripped  from  the  muscular  layers.     J.  H. 
Clayton  (Brit.  Med.  Jour.,  Mar.  24,  '94). 
The  presence  of  rupture  of  the  stom- 
ach can  be  ascertained  by  inflating  the 
organ    with    hydrogen-gas    through    an 
elastic  stomach-tube.     If  the  organ  be 
dilated   by   this   procedure,   penetration 
beyond  the  mucous  coat  is  improbable. 
If   the    stomach    cannot   be    distended, 
complete  rupture  has  taken  place,  and 
tympanites,  due  to  the  presence  of  the 
gas  in  the  cavity  proper,  will  be  recog- 
nized. 

Eupture  of  the  stomach  implicates  the 
peritoneal  coat  in  the  majority  of  cases, 
the  elasticity  of  the  peritoneal  invest- 
ment being  less  than  that  of  the  two 
internal  coats:  muscular  and  mucous. 
The  contents  of  the  stomach,  or  a  por- 
tion of  them,  escape  into  the  peritoneal 
cavity  and  cause  severe  suffering  and 
shock,  followed  promptly  by  death  or 
septic  peritonitis. 


ABDOMEN.    CONTUSION.    DIAGNOSIS. 


Lesions  of  the  Liver. — The  liver,  owing 
to  its  friable  nature,  its  size,  and  its 
anatomical  position,  is  the  organ  most 
frequently  injured,  because  indirect  con- 
cussion may  cause  a  profound  lesion.  A 
fall  from  a  great  height  into  water  may 
thus  cause  a  gaping  rent  of  the  capsule 
and  parenchyma  and  open  a  large  num- 
ber of  vessels.  Severe  and  sudden  blows 
of  any  kind,  especially  those  involving 
much  surface,  over  the  abdominal  wall 
may  thus  cause  injury  to  this  organ. 
Again,  its  softness,  which  may  be  in- 
creased by  hypertrophy,  causes  it  to 
yield  readily  to  the  crushing  produced 
by  carriage-wheels,  ear-bumpers,  etc. 

The  severity  of  all  the  general  symp- 
toms is  usually  increased.  The  pain, 
when  the  liver  is  seriously  injured,  is 
peculiar;  it  radiates  from  the  right 
hypochondrium  to  the  waist,  the  scro- 
biculus  cordis,  or  the  scapular  region. 
The  respiration  is  generally  embar- 
rassed; there  is  marked  shock.  Examina- 
tion of  the  fseces  may  show  the  absence 
of  bile,  especially  if  the  bile-duct  is  rupt- 
ured: an  occasional  complication.  The 
dissemination  of  bile  in  the  system  causes 
itching  and,  after  a  time,  jaundice. 
The  escape  of  bile  into  the  peritoneal 
cavity  may  not  give  rise  to  peritonitis, 
however,  this  fluid  being  aseptic.  A 
serous  exudate  may  result  from  the  irri- 
tation caused  by  its  presence,  forming  a 
composite  fluid  which  may  be  retained 
in  the  peritoneal  cavity  a  considerable 
time. 

Case  in  which,  after  severe  contusion 
in  the  hepatic  region,  swelling,  with 
considerable  rise  of  temperature,  super- 
vened. Incision  in  the  median  line.  A 
cavity,  from  which  about  a  quart  of 
reddish  fluid  issued,  found.  Recovery. 
Lyonnet  and  Jaboulay  (Lyon  M6d.,  No. 
10,  '95). 

Case  of  rupture  of  the  liver  in  which 
there    was    copious    exudation    into   the 


abdominal  cavity.  Urine  containing 
bile;  stools  ash-gray.  Seven  quarts  of 
dark  mahogany-colored  fluid  withdrawn, 
and  found  to  contain  much  biliary  pig- 
ment, especially  biliverdin.  Recovery. 
Eoux  (Le  Bull.  M6d.,  Dec.  8,  '95). 

A  rent  is  probable  after  a  severe  injury 
if  there  is  collapse,  if  the  pulse  becomes 
more  rapid  and  small,  if  the  patient 
shows  signs  of  exsanguinity,  if  the  area 
of  liver-dullness  on  percussion  is  in- 
creased, and  if  pain  radiating  to  the 
scapular  region  is  complained  of.  Severe 
injury  may  exist,  however,  without  these 
indications. 

Diagnosis  of  rupture  of  the  liver  is  ren- 
dered difficult  by  the  fact  that  the  local 
symptoms  do  not  arise  till  late,  while 
the  danger  is  greatest  during  the  first 
twenty- four  hours.  Zeidler  (Deutsche 
med.  Woch.,  Sept.  13,  '94). 

Case  of  a  boy,  aged  16,  run  over  by 
a  cart  which  had  passed  over  his  abdo- 
men. The  boy  walked  a  quarter  of  a 
mile  to  the  hospital.  Wlien  admitted  he 
was  pale  and  in  great  pain,  but  his  pulse 
was  full;  no  external  signs  of  injury. 
On  the  fifth  day  he  had  an  action,  ac- 
companied with  severe  abdominal  pain, 
speedily  followed  by  collapse  and  sudden 
death.  Fissure  three  inches  deep  was 
found  in  the  right  lobe  of  his  liver. 
Thomas  Bryant  (Lancet,  Nov.  2,  '95). 

Lesions  of  the  Gall-lladder  or  Biliary 
Ducts.- — -Blows  and  other  conditions 
capable  of  causing  hepatic  rents  some- 
times implicate  these  organs  in  the  le- 
sion. There  may  be  severe  pain  in  the 
right  hypochondrium  if  a  rupture  exists, 
vomiting  of  food  and  bile,  and  icterus. 
The  urine  is  usually  dark-mahogany  and 
the  stools  ash-gray  in  color.  Tender- 
ness over  the  hepatic  region  is  usually 
marked.  The  intensity  of  the  symptoms 
depend  to  a  degree  upon  the  quantity 
of  bile  voided  into  the  abdominal  cavity; 
but,  this  secretion  being  aseptic,  peri- 
tonitis only  occurs  as  a  complication 
when  the  peritoneum  is  itself  implicated 


ABDOMEN.     CONTUSION.    DIAGNOSIS. 


in  the  traumatism,  or  when  the  lesion 
is  at  the  junction  of  the  biliary  tract  and 
the  intestinal  canal,  the  latter  in  that 
case  acting  as  a  source  of  infection. 

Case  of  a  man  \vhOj  after  a  severe  blow 
in  the  right  hypochondrium  from  the 
shaft  of  a  cart,  showed  all  the  symptoms 
of  rupture  in  the  biliary  tract.  Seven 
quarts  of  a  dark-brown  liquid,  rich  in 
biliary  pigments,  biliverdin,  etc.,  with- 
drawn on  the  fourth  day  by  paracentesis. 
Prompt  recovery.  Jules  Eoux  (Mar- 
seille-med.,  Aug.  25,  '95). 

Case    of   rupture    of    the    gall-bladder 
by    contusion.      Inflammation    developed 
slowly  and  death  resulted  in  three  days. 
Post-mortem  showed  the  patient  had  a 
large   gall-bladder   with   numerous    gall- 
stones.    If  an  operation  had  been  made 
early  the  chances  would  have  been  favor- 
able.     McLaren     (Journal    Amer.    Med. 
Assoc,  July  9,  '98). 
Lesions  of  the  Spleen. — The  causes  of 
injury   to   this   organ   are   the   same   as 
those  of  the  liver.     Eents,  sanguineous 
infiltration,  and  partial  crushing  are  the 
lesions  most  frequently  observed.     En- 
largement   of    this    organ    through    a 
malarial  cachexia  renders  it  susceptible 
to  lesions  which  traumatism  would  not 
give  rise  to  were  it  in  its  normal  state. 

In  extensive  lesions  copioiis  hsamor- 
rhage  usually  takes  place  and  death 
rapidly  follows.  If  the  lesion  present  is 
less  severe,  however,  and  the  hsemor- 
rhage  be  moderate,  there  is  tendency  to 
collapse,  increasing  pallor,  and  a  feeling 
of  suffocation.  The  latter  symptom  and 
severe  radiating  pain  in  the  region  of 
the  spleen  are  generally  present,  besides 
the  signs  pecidiar  to  all  abdominal  in- 
juries. If  the  patient  survives  suffi- 
ciently long  the  immediate  effects  of  the 
traumatism,  peritonitis  or  abscess  and 
other  complications  frequently  result. 
Severe  local  pain  generally  continues  for 
some  time,  and  chills  are  not  infrequent. 
Percussion  shows  the  organ  to  be  more 
or  less  enlarged. 


Case  of  young  man  who  fell  from  his 
horse  and  was  struck  on  left  side  of 
thorax  low  down  in  the  axillary  line  by 
animal's  hind  hoof.  Brought  to  hospital 
in  state  of  shock.  Patient  complained  of 
considerable  pain  over  the  left  side  of  the 
lower  ribs,  rather  toward  the  back.  In- 
fusion of  1200  centimetres  of  sterile  salt 
solution  given.  Next  day  symptoms  of 
internal  injury  were  apparent.  Opera- 
tion. The  peritoneum  purplish  in  color, 
bulged  forward,  and  peritoneal  cavity 
completely  filled  with  blood-clots  and 
fluid  blood.  Kupture  of  spleen  found. 
Spleen  removed,  together  with  blood- 
clots  in  peritoneal  cavity.  At  this  stage 
of  operation  patient  was  in  a  moribund 
condition.  Vein  in  arm  was  opened,  and 
saline  infusion  of  2000  centimetres  given. 
Recovery  uneventful.  Charles  McBumey 
(Med.  Record,  Apr.  23,  '98). 

Four  successful  cases  of  splenectomy 
for  rupture  without  external  wound.  Di- 
agnosis of  ruptured  spleen  is  arrived  at 
from  (1)  the  locality  of  the  injury;  (2) 
the  evidence  of  internal  haemorrhage, 
and  (3)  the  large  fixed  dullness  in  the 
left  flank.  Ballance  (Practitioner,  Apr., 
'98). 

In  diagnosis  of  rupture  of  the  spleen 
vomiting  is  a  most  important  guide;  in 
simple  contusion  of  the  alimentary  tract 
it  seldom,  if  ever,  occurs. 

After  injury,  the  patient  may  be  able 
to  walk  or  drive  for  half  an  hour  or  even 
more.  Then  there  is  a  feeling  of  acute 
pain  in  the  splenic  region,  and  a  sense 
of  extreme  weakness.  On  examining  the 
body  the  splenic  region  is  tender,  dull  on 
percussion,  and  rigid.  There  is  pain  on 
deep  inspiration,  the  breathing  is  short 
and  jerky,  and  a  fracture  of  the  ribs  may 
be  suspected.  Pain  spreads  over  the  ab- 
domen; abdominal  distension  and  rigid- 
Itj'  become  apparent,  especially  in  the 
upper  left  quadrant  of  the  abdomen. 
Symptoms  of  hemorrhage  now  develop 
rapidly,  pallor,  extreme  anxiety,  thirst, 
small  frequent  pulse,  and  vesical  tenes- 
mus. Trendelenburg  (Deut.  med.  Woch., 
Oct.  5,  '99). 

Enlargement  and  disease  of  the  spleen 
greatly  predispose  to  rupture.  Haemor- 
rhage is  the  most  constant  symptom, 
though  this  may  be  caused  by  rupture  of 


ABDOMEN.     CONTUSION.     DIAGNOSIS. 


the  mesentery  or  liver.  More  charac- 
teristic and  less  constant  is  pain  in  the 
region  of  the  spleen  and  of  more  impor- 
tance is  dullness  of  the  percussion-note 
extending  over  the  left  upper  abdominal 
and  left  lumbar  regions.  When  let  alone 
a  rupture  of  the  spleen  is  almost  always 
fatal  from  haBmorrhage.  Lewerenz  (Ar- 
chiv  f.  klin.  Chir.,  B.  60,  H.  4,  1900). 

Lesions  of  the  Kidmeys. — The  kidney 
is  firmly  held  in  place  by  its  attachments, 
while  its  consistence  is  such  as  to  pre- 
clude elasticity.  Hence,  a  blow  or  undue 
pressure  may  cause  rupture.  All  the 
causes  of  injury  that  may  take  part  in 
the  production  of  lesions  elsewhere  may 
also  induce  renal  lesions,  which  may  con- 
sist of  contusion,  rupture,  or  laceration. 

Thirty-six  cases  of  renal  lesions  of 
traumatic  origin.  An  abundant  liEemor- 
rhage  may  take  place  without  any  rupt- 
ure from  tearing  of  the  vascular  net- 
work surrounding  the  organ,  and  which 
sometimes  becomes  engorged.  Guter- 
bock  (La  Semaine  Med.,  July  3,  '95). 

Haematuria  is  valuable  only  as  show- 
ing the  fact  of  rupture  of  the  kidney, 
but  not  as  a  symptom  by  which  to  de- 
cide on  operating.  It  is  not  the  visible 
loss  of  blood  by  the  bladder,  but  the 
easily  overlooked,  but  far  more  danger- 
ous, bleeding  into  the  perinephric  tissues, 
or  into  the  peritoneal  cavity,  that  should 
receive  the  chief  attention.  W.  W.  Keen 
(Annals  of  Surg.,  Aug.,  '96). 

Injury  of  the  kidney  and  parenchyma- 
tous nephritis.  Case  of  a  boy,  aged  7, 
who  was  run  over  by  a  coal-cart,  the 
wheels  of  which  passed  over  the  right  leg 
and  the  right  lumbar  region.  On  ca- 
theterization immediately  after  the  acci- 
dent, 2  ounces  of  normal  urine  with- 
drawn. No  pain.  Two  hours  later  he 
passed  12  ounces  of  bloody  urine.  Ex- 
amination made  thereafter  showed  hajma- 
turia.  The  blood  from  the  body  gave 
indications  of  leucocytosis.  The  condi- 
tion of  the  kidney  gradually  improved 
with  rest  in  bed,  and  six  weeks  after  the 
injury  the  patient  discharged  as  recov- 
ered. J.  Yarrow-  fN.  Y.  Med.  .Jour.,  .Jan. 
6,  1900). 


Besides  the  symptoms  common  to 
severe  abdominal  traumatism  there  may 
be  increased  pain  in  the  lumbar  region 
with  radiations  in  the  direction  of  the 
pubis  and  rigidity  of  the  muscles.  Dull- 
ness on  percussion  is  sometimes  elicited. 
Anuria  may  also  occur,  but  this  is  not 
a  characteristic  sign.  Hsematuria  is  an 
important  indication  of  renal  laceration, 
howeyer,  although  it  may  not  present 
itself  at  once;  it  may  be  followed  by  the 
appearance  of  pus.  The  catheter  should 
be  used  in  these.  Eetraction  of  the 
testicles  is  also  said  to  occur  (Kayer). 
The  ureter  is  very  rarely  involved;  when 
it  is,  the  symptoms  are  not  modified. 
Enlargement  of  the  lumbar  and  hypo- 
chondriac regions  is  present  in  the  ma- 
jority of  severe  cases,  but  may  supervene 
late  in  the  history  of  the  case. 

Thanks  to  the  compensatory  work  of 
the  uninjured  kidney,  the  mortality  of 
renal  lesions  is  not  so  marked  as  when 
other  abdominal  organs  are  injured. 

Statistics  of  120  cases,  showing  53  re- 
coveries and  67  deaths:    a  mortality  of 
53.7    per    cent.      Eeckzy     (Wiener    klin. 
Woeh.,  Nov.  8,  '88). 
Even  severe  wounds  have  been  known 
to  heal.     If  large  renal  vessels  are  torn, 
marked     lividity     occurs,     the     patient 
rapidly    becoming    exsanguine.      Death 
may   thus  follow   very   soon.      Involve- 
ment of  the  peritoneum  in  the  injury  is 
promptly    followed    by    peritonitis,    the 
signs  of  this  affection  appearing  a  few 
hours   after  the  receipt   of  the   injury. 
Sepsis  is  not  an  infrequent  complication 
in  unoperated  cases. 

Statistics  of  118  cases  published  since 
1878,  50  of  which  were  fatal.  In  M  of 
these  the  fatal  result  was  due  to  primary, 
continuous,  and  secondary  haemorrhages 
combined  with  shock,  while  suppuration, 
including  peritonitis,  caused  death  in  16 
cases.  W.  W.  Keen  (Annals  of  Surg., 
Aug.,  '96). 

Case  of  boy  run  over  by  heavy  wagon. 


10 


ABDOMEN.    CONTUSION.    PROGNOSIS. 


resulting  in  fi-acture  of  right  lower 
ribs;  symptoms  of  internal  lisemorrhage 
pointed  to  right  kidney.  When  abdo- 
men was  opened,  spleen  had  been  com- 
pletely severed  from  remainder  of  organ 
and  forced  to  right  side  of  abdomen. 
Eight  kidney  was  so  badly  crushed  that 
it  had  to  be  removed.  Remnant  of 
spleen  removed.  Boy  died  in  twenty- 
four  hours.  At  autopsy  it  was  found 
that  left  kidney  had  been  torn  completely 
through.  Robert  Abbe  (Med.  Record, 
Apr.  23,  '98). 

Injuries  to  the  ureter  in  addition  to 
the  general   symptoms  of  shock,  which 
may   subside   within   a   few   hours,    are 
characterized  by  the  appearance  of  little 
blood  in  the  urine  and  perhaps  only  an 
occasional  clot.     If  no  lesion  of  an  ab- 
dominal  organ   accompanies  rupture   of 
the  ureter,  no  very  great  symptoms  will 
be    manifested.      Transient    hcematuria 
should  not  be  overlooked,  especially  with 
persistent    pain    in    the     side.      C.     L. 
Scudder   (Boston  Med.  and  Surg.  Jour., 
May  2,  1901). 
Prognosis.  —  Death  almost  invariably 
attended  rupture  of  the  intestinal  tract 
prior  to  the  introduction  of  exploratory 
abdominal  section,  and  prompt  resort  to 
active  surgical  procedues,   when  neces- 
sary, is  indicated. 

Chavasse  has  collected  thirty-six  cases 
of  kicks  in  the  abdomen  by  horses, 
thirty-five  of  which  died.  A  man  who 
has  been  kicked  in  the  abdomen  by  a 
horse  has  one  chance  out  of  three  of 
dying.  More  than  one-half  of  personal 
cases  saved,  thanks  to  intervention, 
although  it  is  true  that  some  eases  were 
opened  which  might  have  recovered 
spontaneously.  The  laparotomy  did  no 
harm.  Intervention  should  be  practiced 
when  there  are  sharp,  local  pains  and 
rapid  elevation  of  temperature.  Kir- 
misson  (La  France  Med.,  No.  14,  '95). 

Three  hundred  and  seven  cases  of  con- 
tusions of  the  abdomen,  from  the  kick 
of  a  horse,  treated  without  operation, 
found  in  literature;  215  recovered  and 
92  died.  Of  36  cases  in  which  operation 
was  practiced,  26  died  and  12  recovered, 
and  in  only  3  of  these  could  operation 
have    been    considered    as    imperatively 


necessary.  As  soon  as  a  patient  is  kicked 
in  the  abdomen  by  a  horse,  he  should 
be  taken  to  a  hospital,  a  careful  history 
of  the  accident  taken  down,  and  the  pa- 
tient treated  expectantly.  He  should  be 
placed  in  bed,  heat  applied,  pain  relieved, 
and  should  be  given  no  food;  evei-y  half- 
hour  the  temperature  and  respiration 
should  be  recorded,  with  a  note  of  the 
general  condition  and  the  local  symp- 
toms. The  moment  that  peritoneal  reac- 
tion or  general  infection  is  evident  the 
abdomen  should  be  opened.  Seven  cases 
personally  witnessed  in  which  recovery 
occurred  without  operation.  Nimier 
(Arch,  de  M6d.  et  de  Pharm.  Mil.,  Mar., 
'98). 

Where  abdominal  contents  are  rupt- 
iired  96  per  cent,  of  cases  die.  Early 
operation  favored.  John  T.  Rogers  (Jour. 
Amer.  Med.  Assoc,  July  9,  '98). 

As  to  the  liver,  as  late  as  1864  wounds 
of  this  organ  were  considered  as  practi- 
cally hopeless  in  every  instance.  "While 
a  very  small  proportion  of  these  cases 
recover  without  surgical  interference,  as 
is  shown  by  the  scars  occasionally  found 
in  the  hepatic  parenchyma,  the  fact  re- 
mains that  an  exploratory  laparotomy, 
permitting  the  surgeon  to  quickly  arrest 
the  loss  of  blood  in  case  of  hemorrhage 
and  to  rid  the  peritoneal  cavity  of  ac- 
cumulated extraneous  fluids,  has  greatly 
reduced  the  mortality.  The  prognosis 
becomes  much  more  unfavorable  when 
peritonitis  has  set  in,  but  a  fatal  issue 
may  sometimes  be  averted,  even  in  ad- 
vanced cases  of  this  complication,  by 
surgical  intervention. 

Case  in  a  girl,  aged  9,  who,  four  days 
after  receiving  a  kick,  came  under  treat- 
ment, with  well-marked  peritonitis.  On 
the  fifty-second  day  abdominal  section; 
adhesions  found  everywhere.  Neverthe- 
less almost  steady  recovery.  A  year 
afterward  the  child  seen  and  in  perfect 
health.  Greiffenhagen  (St.  Petersburg 
med.  Woch.,  Apr.  25,  '92). 

The  same  remarks  apply  to  rupture 
of  the  gall-bladder. 


ABDOMEN.     CONTUSION.     PROGNOSIS. 


11 


Case  of  rupture  of  the  gall-bladder  due 
to  a  blow  upon  the  abdomen.  Three 
weeks  after  the  accident  laparotomy 
was  performed  with  the  removal  of 
three  quarts  of  brownish  fluid  contain- 
ing numerous  blood-clots.  Convalescence 
slow,  but  complete.  Thomas  (Deutsche 
med.  Woch.,  July  14,  '92). 

Slight  contusions  of  spleen  heal  read- 
ily, but  rents  and  tears  of  any  impor- 
tance are  frequently  followed  by  fatal 
hsemorrhage.  Abscesses  occasionally 
complicate  convalescence. 

Case  of  V-para  of  31  in  sixth  month 
of  pregnancy.  Drunken  man  had  trod- 
den on  the  left  side  of  her  abdomen;  on 
following  day  there  were  signs  of  inter- 
nal haemorrhage.  Laparotomy  disclosed 
rupture  of  spleen  as  source  of  bleeding. 
Spleen  extirpated  and  the  woman  made 
excellent  recovery  and  was  spontaneously 
delivered  of  a  healthy  child  at  full  term. 
Tabulated  eight  reported  cases  of  re- 
moval of  spleen  for  injury,  five  recoveries. 
Savor   (Centralb.  f.  Gyn.,  1305,  '98). 

The  great  majority  of  cases  of  rupture 
of  the  kidney  that  recover  are  those  in 
which  the  initial  lesion  had  been  com- 
paratively slight.  In  the  graver  cases, 
in  which  there  is  copious  hsemorrhage 
into  the  perinephric  tissues  or  into  the 
peritoneal  cavity,  of  which  the  growing 
exsanguinity  of  the  patient  is  an  indi- 
cation, the  prognosis  depends  upon  the 
speed  with  which  adequate  surgical  pro- 
cedures are  instituted.  Occasionally, 
however,  the  blood  is  held  in  check  by 
the  renal  capsule. 

The  prognosis  depends  greatly,  there- 
fore, upon  the  patient's  ability  to  stand 
operative  procedures  suitable  to  estab- 
lish a  positive  diagnosis  and  bring  the 
lesion  that  may  at  any  moment  destroy 
life  within  the  immediate  reach  of  art's 
highest  powers.  When  serious  injury  is 
rendered  probable  by  the  nature  of  the 
accident,  and  the  symptoms  present 
also  indicate  a  serious  lesion,  an  explo- 


ratory incision,  if  the  patient  is  not  past 
relief,  a  careful  examination  of  the  or- 
gans involved,  arrest  of  haemorrhage, 
closure  of  the  disrupted  tissues,  or  cleans- 
ing of  the  abdominal  cavity  may  save 
him  even  when  his  condition  appears 
almost  hopeless. 

Again,  the  prognosis  is  influenced  by 
the  time  elapsing  between  the  accident 
and  the  institution  of  surgical  proced- 
ures. The  sooner  they  are  resorted  to, 
all  things  considered,  the  greater  the 
chances  of  success. 

No  case  can  be  considered  as  hopeless 
imless  a  subnormal  temperature,  cold 
and  cyanosed  extremities,  and  other 
signs  indicate  that  the  end  is  near. 

A  case  may  be  considered  as  inoperable 
when  there  is  profound  collapse,  the 
tongue  being  cold,  the  extremities  cya- 
nosed with  an  imperceptible  pulse,  and  a 
temperature  ranging  from  96°  to  97°  F. 
Editorial  (La  Med.  Mod.,  Feb.  15,  '96). 

A  case  of  penetrating  gunshot  wound 
of  the  abdomen  in  which,  nearly  ten 
weeks  afterward,  the  bullet,  weighing  20 
grammes,  was  extracted.  The  intestines 
were  not  opened,  the  entire  fistulous 
tract  being  dissected  out.  He  recovered 
in  six  weeks.  The  bullet  had  a  steel 
casing,  and  its  deformity  showed  that  it 
had  already  struck  once  and  had  then 
been  deflected.  Calcareous  particles  and 
bits  of  clothing  were  found  in  the  ab- 
dominal fistula.  M.  Hassler  (Jour,  de 
Med.  de  Bordeaux,  Feb.  3,  1901). 
Even  when  performed  late  in  the  his- 
tory of  the  case,  the  operative  measures 
sometimes  prove  successful. 

Case  in  which  blow  on  abdomen  caused 
rupture  of  pancreas  followed  by  rapid 
formation  of  larger  pancreatic  cyst  simu- 
lating closely  an  abdominal  aneurism. 
Four  week's  after  injury  cyst  evacu- 
ated through  the  abdominal  incision 
and  drained.  Critical  condition  of  pa- 
tient contra-indicated  attempt  to  suture 
wound  in  pancreas.  On  third  day  fol- 
lowing operation  subphrenic  abscess  was 
evacuated  through  a  bronchus  and  pa- 
tient rapidly  recovered.     There  was  pro- 


13 


ABDOMEN.     CONTUSION.     TREATMENT. 


fuse  discharge  of  pancreatic  fluid  from 
abdominal  wound.  The  cyst  contracted 
to  small  sinus,  Avhich  healed  on  seventy- 
seventh  day  after  operation.  Patient 
fifteen  months  after  injury  was  well  and 
showed  no  functional  disturbance  of  any 
alimentary  process.  H.  W.  Gushing 
(Jour.  Amer.  Med.  Assoc.,  Mar.  7,  '98). 

The  early  recognition  of  a  rupture  of 
the  bladder  greatly  influences  the  prog- 
nosis. About  60  per  cent,  of  the  most 
unpromising  lesion,  intraperitoneal  lac- 
eration, are  saved  by  prompt  surgical 
measures.  The  remaining  40  per  cent, 
are  imsuccessful  mainly  on  account  of 
delay  in  resorting  to  abdominal  section. 
A  successful  result  has,  nevertheless, 
followed  laparotomy  as  much  as  fifty- 
four  hours  after  the  rupture. 

Keviews  of  the  literature  of  32  cases 
collected,  22  of  which  are  intra-  and  10 
extra-  peritoneal.  Of  the  intraperi- 
toneal cases  10  recovered.  Of  the  extra- 
peritoneal ones  7  recovered.  Sehlanger 
(Archiv  f.  klin.  Chir.,  B.  43,  ■92). 

As  a  result  of  surgical  intervention, 
the  mortality  from  traumatic  rupture  of 
the  bladder  has,  during  the  past  fifteen 
years,  been  reduced  fi-om  90  to  about  54 
per  cent.  Of  18  eases  of  extraperitoneal 
rupture  treated  by  operation,  10  ended 
in  recovei-y  and  8  in  death.  Of  34 
patients  in  whom  the  peritoneal  covering 
of  the  bladder  had  been  involved  in  the 
injury,  14  recovered  after  operation  and 
20  died.  Sieur  (Archives  Gen.  de  M6d., 
Feb.,  Mar.,  '94). 

Treatment. — Shock. — Shock  or  col- 
lapse, though  itnreliable  as  a  sign  of 
severe  injury  to  the  abdominal  viscera, 
is,  nevertheless,  an  alarming  condition, 
especially  if  the  temperature  is  subnor- 
mal and  the  breath  is  shallow,  and  it 
should  at  once  receive  attention.  The 
patient  is  placed  in  bed  with  the  head 
low,  and  a  free  supply  of  pure  air  in- 
sured, supplemented  with  oxygen  if  prac- 
ticable. Hot-water  bottles  are  placed 
around    him    and    he    is    covered    with 


blankets  previously  warmed,  if  possible, 
or  wrung  out  of  hot  water. 

Two  main  elements  have  to  be  borne 
in  mind  in  this  class  of  cases:  (1)  that 
the  state  of  shock  is  due  to  a  direct  com- 
motion of  the  sympathetic  system  with 
probable  inhibition  of  the  heart's  action, 
and  (2)  the  possibility  of  an  internal 
lesion  which  may  involve  death  by  ex- 
sanguination  or  the  outpour  into  the 
peritoneal  cavity  of  gastric  or  intestinal 
fluids.  While  the  first  condition  calls 
for  stimulants  adapted  to  sustain  the 
flagging  heart  and  restore  the  action  of 
the  vasomotor,  the  agents  employed 
should  not  be  administered  by  the 
mouth,  since,  in  ease  of  rupture  of  the 
stomach,  the  duodenum,  or  jejunum,  a 
portion,  at  least,  of  the  fluid  may  be 
added  to  those  that  may  have  found 
their  way  into  the  peritoneal  cavity. 
Eectal  and  subcutaneous  injections 
should,  therefore,  be  resorted  to. 

If  no  remedy  be  at  hand,  subcuta- 
neous injections  of  1  drachm  of  whisky 
or  brandy  may  be  employed,  and  re- 
peated every  five  or  six  minutes  until 
reaction  occurs.  A  turpentine  stupe  or 
a  fresh  mustard  poultice  (not  plaster) 
over  the  xiphoid  cartilage,  and  a  rectal 
injection  composed  of  a  tablespoonful 
of  turpentine,  a  raw  egg,  and  a  teacup- 
ful  of  warm  water,  sometimes  act  with 
surprising  rapidity.  Hypodermic  injec- 
tions of  ether,  or,  better  still,  tincture 
of  digitalis  with  V120  grain  of  atropine, 
repeated  in  fifteen  minutes,  are  nec- 
essary to  sustain  cardiac  action.  After 
the  second  dose  the  digitalis  may  be 
injected  alone  several  times  more. 
These  measures  are  greatly  assisted  by 
galvanic  stimulation  of  the  phrenic 
nerve,  the  negative  pole,  moistened  in  a 
solution  of  chloride  of  ammonium,  being 
applied  to  the  neck  in  the  depression 
immediately  in  front  of  the  sterno-mas- 


ABDOMEN.     CONTUSION.     TREATMENT. 


13 


toid  mnscle,  and  the  positive  over  the 
epigastrium. 

These  means  are  sometimes  inefficient 
and  hypodermoclysis  should  be  per- 
formed. If  a  fatal  issue  seems  inevitable, 
saline  transfusion  is  indicated. 

When  the  case  is  not  very  urgent,  and 
the  operator  can  act  with  deliberation, 
hypodermoclysis  should  be  performed. 
When  the  symptoms  are  alarming  and 
life  is  about  to  ebb,  saline  transfusion  is 
indicated.  T.  L.  Rhoads  {Ther.  Gaz., 
Oct.  15,  '97). 

Administration  cf  morphine  indicated 
in  cases  of  great  shock  after  injury.  Use 
of  drug  should  not  be  continued,  one  or 
two  hypodermics  usually  being  sufficient. 
McBurney  (Med.  Record,  Apr.  23,  '08). 

Eeaction.  —  As  soon  as  reaction  oc- 
curs in  these  cases  another  danger 
threatens  the  patient,  that  of  hsemor- 
rhage,  which  the  state  of  collapse  has  so 
far  prevented  to  a  degree,  unless  an 
extensive  injury  have  caused  overwhelm- 
ing exsanguination.  In  this  event,  how- 
ever, the  patient's  recovery  from  the 
preliminary  shock  would  hardly  have 
taken  place.  Hence  the  necessity  of 
closely  watching  the  suSerer. 

After  a  severe  abdominal  injuiy  the 
patient  passes  through  a  stage  of  col- 
lapse, through  a  stage  when  the  diag- 
nosis remains  uncertain,  through  a 
period  when  the  signs  of  hfemorrhage 
show  themselves,  and  through  a  period 
of  slow  complications.  Van  Verts  (Arch. 
G6n.  de  Med.,  Jan.,  '97). 

Cases  of  prolonged  collapse  sometimes 
turn  out  to  be  trivial,  while  a  short 
period  of  it  may  be  the  prelude  to  the 
most  grave  complications.  The  former 
cases  are,  unfortunately,  rare,  and  pro- 
found shock  of  any  duration  should  be 
looked  upon  with  suspicion.  This  is 
especially  the  case  when  a  second  period 
of  shock  is  passed  through — the  "relaps- 
ing collapse"  of  Bryant — indicative  of  a 
secondary    haemorrhage    or    the    giving 


way    or    separation    of    some    damaged 
tissues. 

That  cases,  clearly  showing  by  their 
history  and  the  active  symptoms  a  grave 
injury,  should  be  submitted  to  surgical 
measures  as  early  as  possible  will  hardly 
be  gainsaid  in  the  light  of  our  present 
knowledge.  An  equally  positive  conclu- 
sion, based  on  every  means  of  diagnosis 
available,  will  alone  warrant  the  asser- 
tion that  no  serious  injury  is  present; 
but  if,  on  the  other  hand,  doubt  exists, 
abdominal  section  will  alone  insure  the 
patient  adequate  protection.  If  nothing 
be  found,  no  harm  will  have  been  done 
if  precepts  governing  aseptic  surgery 
have  been  closely  followed;  if  a  rent  in 
the  liver,  an  intestinal  tear  or  rupture, 
a  serious  hemorrhage  be  discovered  and  , 
adequately  dealt  with,  the  patient  will 
have  received  the  benefit  of  all  our  art's 
resources. 

Hyperesthesia  of  abdomen  after  injury 
is  indication  for  operation.  An  increase 
in  respirations  to  twenty-eight  or  thirty 
per  minute  makes  indication  absolute. 
Cold  extremities  also  significant.  Le 
Dentu  (Le  Progres  Med.,  Oct.  27,  '97). 

In  abdominal  injuries  when  there  is 
pain  without  cessation  and  nausea,  it  is 
best  to  operate.  J.  B.  Murphy  (Jour. 
Amer.  Med.  Assoc,  July  9,  '98). 

The  seat  of  rupture  being  located, 
the  nature  of  the  injury  will  deter- 
mine the  procedure  to  follow,  linear 
enterorrhaphy  being  indicated  in  longi- 
tudinal ruptures,  and  circular  enteror- 
rhaphy in  complete  ruptures,  a  Murphy 
button  being  employed.  These  proced- 
ures are  now  generally  preferred  to  an 
artificial  anws.  It  is  sometimes  impos- 
sible to  adequately  adjust  the  edges  of 
the  wound,  owing  to  the  condition  of  the 
margin,  and  an  omental  graft  must  be 
used  to  cover  the  contused  area  so  as  to 
avoid  a  secondary  perforation. 

Considerable   extravasation   of  fseces, 


14 


ABDOMEN.     CONTUSION.     TREATMENT. 


bloody  and  other  liquid  or  semiliquid  ma- 
terial may  have  occurred  into  the  peri- 
toneal cavity.  All  chances  for  further 
contamination  of  the  intestinal  tract 
having  thus  been  removed  by  closure  of 
the  rupture,  the  peritoneal  cavity  should 
be  carefully  cleansed  by  flushing  with 
warm,  sterilized  water,  a  soft  aseptic 
sponge  being  employed  to  gently  mop 
all  the  surfaces  that  may,  in  any  way, 
hav€  come  in  contact  with  the  infectious 
fluids.  The  cavity  is  then  closed  and 
free  drainage  insured. 

Satisfactory  results  are  obtained  even 
in  cases  in  which  very  great  injury  and 
ample  opportunity  for  infection  of  all 
wounds  have  markedly  compromised  the 
issue. 

Case  in  a  young  man  who,  some  time 
previously,  had  been  severely  wounded 
in  the  abdomen  by  a  wagon-pole.  The 
intestines  were  much  contused  and  very 
dirty.  In  some  places  the  serous  and 
muscular  coats  were  torn  through.  The 
intestines  and  peritoneal  cavity  were 
carefully  cleansed  with  a  solution  of 
iodine  terchloride  (1  to  1000)  and  the 
wounds  united.  The  patient  recovered 
without  fever.  Langenbuch  (Deutsche 
med.  Woch.,  Apr.  28,  '92). 

The  after-treatment  should  be  based 
upon  the  necessity  of  insuring  rest  for 
the  intestinal  tract  for  a  few  days.  This 
may  be-  carried  out  by  administering 
■opiates.  The  patient's  strength  should 
be  sustained,  however,  by  means  of 
nutrient,  but  small  and  frequently  ad- 
ministered, enemata. 

Under  all  circumstances,  an  abdomi- 
nal injury  should  cause  the  patient  to  be 
watched  several  days.  After  an  uncom- 
plicated injury  he  should  remain  in  bed 
and  be  placed  on  a  milk  diet  for  a  few 
days.  Anodyne  applications  over  the 
abdomen  and  a  little  morphine,  inter- 
nally, if  there  is  pain,  is  all  that  is  usu- 
ally required  in  these  cases.    In  the  less 


fortunate  the  procedure  to  be  adapted 
varies  according  to  the  organ  involved. 
Intestines. — The  probability  of  a  rupt- 
ure having  been  recognized,  the  abdo- 
men should  be  opened  by  an  incision 
through  the  linea  alba,  and  any  haemor- 
rhage quickly  arrested.  The  next  step 
is  to  locate  the  visceral  injury.  Of  im- 
portance in  this  connection  is  the  fact 
that  in  the  majority  of  cases  the  rupt- 
ure is  due  to  compression  against  the 
spinal  column.  The  spot  over  the  abdo- 
men upon  which  the  blow  carried  being 
considered  as  the  one  end  of  an  imagi- 
nary line  and  the  centre  of  the  vertebral 
column  as  the  other  end,  the  probabili- 
ties are  that  the  rupture  will  be  found 
near  the  linear  axis. 

In  dogs  with  intestinal  perforation 
there  is  constriction  of  the  intestine 
above  and  below  the  point  of  injury,  and 
swelling  of  the  intestinal  loop  at  the 
point  of  lesion.  Lesions  are  always 
superposed  in  the  direction  of  the  spine; 
so  that  by  going  from  injured  portion  of 
wall  toward  the  spine  the  wounded 
loops  are  always  found.  Fgvrier  and 
Adam  (Revue  Int.  de  Med.  et  de  Chir., 
Oct.  25,  '94). 

Four  eases  of  abdominal  sections  for 
severe  injuries  without  external  wounds. 
One  should  make  a  careful  exploration 
of  viscera  before  closing  parietal  incision. 
Three  of  the  cases  reported  terminated 
fatally  and  at  the  autopsy  it  was  dis- 
covered in  two  cases  that  a  wound  of  the 
intestinal  tract  had  been  overlooked. 
A.  M.  Shield  (Practitioner,  Nov.,  '98). 

Again,  if  the  rupture  cannot  be  read- 
ily found,  hydrogen  may  be  insufflated 
into  the  rectum,  as  advised  by  Senn,  and 
the  spot  from  which  the  gas  escapes  will 
indicate  the  location  of  the  rupture, — 
approximately,  in  the  case  of  the  small 
intestine,  and  accurately  below  the  ileo- 
csecal  valve. 

Disorders,  or  lesions  other  than  those 
sought  after,  are  misleading  conditions 
that  should  be  borne  in  mind. 


ABDOMEN.     CONTUSION.     TREATMENT. 


15 


Lesions  of  the  jejunum  are  sometimes 
difBcult  to  locate. 

Ruptui'e  of  the  jejunum.  The  patient 
was  struck  by  the  back  rail  of  a  barrow, 
across  the  upper  part  of  the  abdomen; 
severe  pain,  but  not  fainting.  He  was 
able  to  push  the  barrow  a  little  further 
and  to  walk  about  a  mile.  No  wound 
nor  any  bruising  evident  over  the 
abdomen;  very  little  tenderness,  and 
breathing  not  markedly  thoracic.  Tem- 
perature, 97°  F. ;  pulse,  80  and  weak. 
On  the  day  follo\^■ing  peritonitis  present, 
and  laparotomy  performed  by  Mr. 
Cheyne.  At  the  upper  part  of  the 
cavity,  behind  the  liver  and  stomach, 
the  peritonitis  was  most  acute,  and  a 
rent  was  found  in  the  upper  end  of  the 
jejunum.  Patient  returned  to  bed  very 
much  collapsed  and  died  nine  hours 
after  the  operation.  C.  J,  Hood  (Brit. 
Med.  Jour.,  Apr.  5,  '90). 

Stomach.  —  Wlien  the  sjaiiptoms  of 
complete  tear  are  recognized,  the  pres- 
ence of  the  organ's  contents  in  the 
abdominal  cavity  render  an  immediate 
laparotomy  imperative.  The  incision 
should  include  the  tissues  between  the 
xiphoid  cartilage  and  the  umbilicus.  If 
the  tear  cannot  be  quickly  found,  repe- 
tition of  the  inflation  with  hydrogen-gas 
will  help  to  locate  it.  As  soon  as  located 
any  bleeding  vessel  should  be  ligated, 
and  the  stomach  evacuated  and  cleansed 
through  the  adventitious  opening  of  any 
substance  that  may  have  remained  in  it. 
If  the  wound  be  a  lacerated  one,  it  may 
be  necessary  to  pare  its  edges.  This  be- 
ing done,  the  tear  is  closed,  the  mucous 
membrane  being  united  with  a  contin- 
uous or  interrupted  suture,  cut  short, 
and  the  muscular  and  serous  coats  by 
the  continuous  Lembert  suture.  Closure 
of  the  laceration  having  removed  all 
danger  of  further  extravasation  into  the 
peritoneal  cavity,  the  latter  must  be 
flushed  with  warm,  sterilized  water  and 
mopped  out  with  a  soft  sponge.  The 
cavity  is  then  closed  and  a  drain  left  if 


the  peritoneal  surfaces  have   been   ex- 
posed to  contamination  for  some  time. 

Experiments   in    cats   in    which    large 
openings  in  the  stomach  we  successfully 
closed  by  means  of  an  omental  plug.    The 
surrounding    mucous    membrane    always 
prolapsed  freely  and  the  piece  of  omen- 
tum,  already   fixed   to   the   serous   coat 
close  to  the  seat  of  excision,  was  sewn 
around   the   wound,   the   omental   tissue 
being  fixed  to  the  serosa.     A  process  of 
omentum  was  then  sewn  over  the  whole, 
this  being  necessary  in  the  case  of  cats, 
owing  to  the  thinness  of  the  omentum. 
The  transplantation  not  only  succeeded, 
but    the    omental    tissue    gradually    as- 
sumed the  character  of  gastric  mucous 
membrane.      Well-formed    glands    devel- 
oped.     Enderlen    (Deut.    Zeit.    f.    Chir., 
Apr.,  1900). 
Liver. — Especially  when  the  history  of 
the  case  seems  to  indicate  the  possibility 
of  a  lesion  of  this  organ  is  careful  watch- 
ing  imperatively    demanded,    owing    to 
the  violent  lijemorrhages  which  they  in- 
volve.   Either  this  complication  or  peri- 
tonitis having  been  recognized,  the  ab- 
domen  should   be    opened   at    once   in 
the  middle  line.    The  abdominal  wound 
should  be  large  enough,  if  possible,  for 
the  surgeon  to  see  the  liver,  but  in  every 
case  he  ought  to  make  a  careful  explora- 
tion with  his  finger,  especially  directing 
his  attention  to  the  convex  and  posterior 
surfaces  of  the  organ. 

When  a  rupture  is  fotind,  the  wound 
may  either  be  cauterized,  plugged,  or 
sutured. 

Paquelin's  cautery  can  hardly  arrest 
haemorrhage  from  large  vessels  in  deep 
wounds  of  the  liver;  here  the  suture 
may  be  used.  The  blood-pressure  in  the 
liver-vessels  is  low;  hence  arrest  of 
hEEmorrhage  can  surely  be  obtained  by 
the  tampon.  The  wound  in  the  liver 
can  also  be  better  observed  where  the 
tampon  is  used.  Three  personal  cases  in 
which  the  measures  were  successful. 
Weidler  (Deutsche  med.  Woch.,  Sept.  13, 
'94). 

Where  the  wound  is  a  large  one  the 


16 


ABDOMEN.     CONTUSION.     TREATMENT. 


combination  of  sutures,  mattress-sutures, 
and  tamponade  may  be  necessary;  but, 
as  a  rule,  the  tampon  should  be  used 
only  in  cases  where  sutures  have  failed 
to  check  the  haemorrhage.  Of  the  three 
methods  the  thermocautery  is  of  least 
value;  it  will  check  only  moderate 
parenchymatous  haemorrhage,  is  of  no 
value  in  extensive  wounds,  and  is  apt 
to  be  followed  by  secondary  hsemor- 
rhage.  Schlatter  (Annals  of  Surg.,  Apr., 
'97). 

A  jet  of  steam  to  control  haemorrhage 
from  the  contused  liver  or  omentum, 
first  recommended  by  Sneguirefl,  has 
antiseptic  as  well  as  hsemostatic  virtues. 
When  the  tampon  is  employed,  the  sur- 
rounding peritoneal  cavitj'  should  be 
shut  off  by  a  feAv  sutures.  Doyen  (Le 
Progres  M6d.,  Oct.  30,  '97). 

Plugging  with  antiseptic  or  aseptic 
gauze  seems  to  give  the  best  results,  one 
end  of  the  gauze  being  left  out  at  the 
angle  of  the  abdominal  wound.  The 
plug  should  be  removed  not  earlier  than 
the  forty-eighth  hour,  lest  there  should 
be  a  recurrence  of  the  haemorrhage,  and 
not  later  than  the  fourth  day,  lest  a  bil- 
iary fistula  should  be  formed.  When  the 
bleeding  is  very  severe  sponges  mounted 
on  holders  appear  to  produce  more  satis- 
factory pressure  than  simple  plugging, 
which  is,  perhaps,  better  reserved  for 
slighter  injuries.  Hot-water  irrigation 
may  be  of  advantage  in  these  cases.  A 
ligature  should  be  applied  to  any  large 
vessel  which  is  seen  to  have  been  torn. 
Sutures  are  particularly  useful  when  the 
laceration  extends  deeply  into  the  sub- 
stance of  the  liver,  since  by  their  means 
the  edges  of  the  wound  may  be  brought 
lightly  together  and  the  bleeding  can 
be  controlled.  Drainage  of  the  pelvic 
pouch,  by  an  opening  just  above  the 
pubis,  serves  best  to  give  free  passage 
to  subsequent  discharges.  The  capsule 
should  be  included  in  the  stitches.  The 
prognosis  is  very  unfavorable  when  peri- 
tonitis has  occurred,  but  something  may 


still  be  done  to  prevent  the  fatal  issue 
by  opening  and  afterward  draining  the 
abdominal  cavity. 

Two  cases  of  rupture  of  the  right  lobe 
in  a  woman  of  21  years  struck  by  a  train. 
Rent  found  in  the  under  surface  of  the 
liver,  2  V:  inches  long,  and  I  Vs  inches 
deep;  also  several  small  rents  in  the 
spleen.  Wound  closed.  Rapid  recovery. 
Case  of  a  man,  44  years  old,  caught  be- 
tween two  cars.  Rent  in  the  under  sur- 
face of  the  liver.  Haemorrhage  was 
checked  by  pressure  with  gauze,  and  the 
abdominal  wound  closed.  Rapid  and 
good  recovery.  H.  B.  Delatour  (Med. 
News,  Eeb.  17,  1900). 

Ruptured  liver  in  a  man  of  25  upon 
whom  a  case  of  glass,  weighing  half  a 
ton,  fell.  Collapse,  pain,  and  tenderness 
in  the  upper  part  of  the  abdomen,  and 
increased  liver-dullness.  Almost  pulse- 
less within  three  and  one-half  hours. 
Intravenous  injection  of  saline  solution 
given,  and  the  abdomen  opened.  Found 
full  of  blood,  and  across  the  under  sur- 
face of  the  liver  was  a  laceration  ex- 
tending from  the  gall-bladder  to  the 
posterior  part.  The  laceration  was 
packed  with  iodoform  gauze,  and  the 
wound  was  approximated.  The  patient 
remained  pulseless  nearly  thirty  hours, 
but  gradually  recovered.  Thomas  Car- 
wardine   (Lancet,  May  12,  1900). 

Spleen. — After  a  simple  contusion  the 
spleen  soon  returns  to  its  normal  condi- 
tion without  further  trouble,  and  a  few 
days  in  bed,  coupled  with  strapping  of 
the  side  to  limit  motion,  usually  suffice. 
When,  however,  there  is  laceration  of  the 
parenchyma  the  convalescence  is  slow, 
abscesses  following  in  quick  succession. 
After  a  time  these  cease  and  recovery  is 
uninterrupted.  Sjanptomatic  treatment, 
revulsion  over  the  organ,  and  tonics  may 
shorten  the  duration  of  such  cases. 

When  the  symptoms  do  indicate  that 
essanguination  of  the  patient  is  taking 
place,  death  will  most  probably  follow, 
although  the  haemorrhage  is  not  as  copi- 
ous as  it  can  be  in  tears  of  the  liver,  the 


ABDOMEN.    CONTUSION.    TREATMENT. 


17 


splenic  capsule  being  more  elastic  than 
that  of  the  latter  organ.  Eemoval  of  the 
organ  should  be  resorted  to.  The  ab- 
dominal wall  is  opened  by  means  of  an 
incision  through  the  left  semilunar  line 
and  the  peritoneum  is  freely  opened. 
The  hand  being  introduced  into  the 
cavity,  all  adhesions  are  torn  up  and  the 
organ  is  brought  to  view.  The  vessels 
entering  the  hilum  are  then  clamped 
and  the  organ  is  removed.  The  stump 
is  ligated  and,  after  sponging  out  the 
abdominal  cavity,  the  wound  is  closed. 

Results    of    splenectomy    for    rupture. 
Study  of  seven  cases  suggests  following 
conclusions:     1.   A   marked   leueocytosis 
follows  removal  of  the  spleen.    It  follows 
immediately  after  removal,  and  continues 
gradually  to  decline ;   lasts  six  months  or 
more.    2.  The  various  forms  of  leucocytes 
are  increased  in  number  in  various  pro- 
portions, and  do  not  bear  the  same  ratio 
to   each   other  as   in  normal   blood.     3. 
The  ansemia  produced  by  the  accident  is 
very  slowly  recovered  from  after  the  re- 
moval  of   the   spleen.     4.   In   a   certain 
number  of  cases  (three  out  of  seven)  the 
removal  of  the  organ  is  followed  at  an 
interval  of  from  ten  days  to  three  weeks 
by  a  train  of  symptoms  characterized  by 
pyrexia,  wasting,  extreme  weakness,  an- 
semia, frequent  pulse,  pallor,  thirst,  and 
headache,  Avhieh  last  for  a  varying  period 
and  are  slowly  recovered  from.     5.  The 
external   lymphatic  glands   undergo   en- 
largement and  in  some  cases  a  marked 
hypertrophy.    George  Heaton  (Brit.  Med. 
Jour.,  Aug.  19,  '99). 
Kidney. — The  majority  of  mild  cases 
of  perirenal  extravasations  of  blood  and 
urine  recover  as  the  result  of  rest  and 
expectant      treatment.        The      patient 
should   be   kept   in   bed    and   his   diet 
limited  to  liquids,  the  best  of  which  is 
milk;  this  beverage  requires,  besides,  the 
least   physiological   labor   from   the   in- 
jured organ.     The  nourishment  of  the 
patient    may    further    be    sustained    by 
rectal  injections  of  beef-tea,  and  these 
should  entirely  be  resorted  to  if  there  is 


vomiting,  the  latter  tending  greatly  to 
encourage  haemorrhage.  When  the  latter 
occurs  in  the  direction  of  the  bladder, 
there  is  likely  to  be  accumulation  of 
blood-clots,  which,  if  small,  will  readily 
pass  out  with  the  urine.  Frequently, 
however,  the  clots  are  large  and  cause 
retention  of  urine  and  marked  tenesmus. 
A  large  catheter  should  therefore  be  in- 
troduced and  kept  in  situ  when  the 
heematuria  is  marked,  and  the  bladder 
occasionally  washed  out  with  a  weak 
boric-acid  solution.  Median  urethrot- 
omy to  remove  clots  and  relieve  reten- 
tion sometimes  becomes  necessary  in 
these  cases.  When  the  symptoms  do  not 
improve  under  these  measures,  an  incis- 
ion should  be  made,  exposing  the  seat  of 
injur}',  the  extravasation  removed,  and 
the  parts  restored,  by  appropriate  meas- 
ures/ to  their  normal  conformation. 

There  is  great  danger  in  delaying 
operation  in  these  cases;  the  decompo- 
sition of  the  clots  and  the  cystitis  which 
is  excited  by  their  presence,  as  well  as 
the  frequent  catheterization  needed,  ex- 
pose the  patient  to  all  the  dangers  of 
suppuration  of  the  wounded  kidney,  and 
also  to  the  risk  of  infection.  Henry 
Morris  (Clin.  Jour.,  Aug.  1,  '94). 

The  dangers  of  rupture  of  the  kidney 
are  mainly  hemorrhage  and  sepsis. 
When,  therefore,  the  symptoms  are  such 
as  to  indicate  marked  haemorrhage  or 
sepsis,  and  especially  if  a  tumor  form 
quickly  in  the  lumbar  region,  an  explora- 
tory operation  should  at  once  be  done. 
If  severe  laceration  be  present,  or  the 
kidney's  functions  be  practically  com- 
promised, or  the  hemorrhage  be  such  as 
to  require  ligation  of  the  renal  vessels, 
kimbar  nephrectomy  should  immedi- 
ately be  performed,  primary  nephrec- 
tomy being  safer  than  secondary  re- 
moval of  the  organ. 

Eleven  cases  of  kidney  traumatisms, 
with   eight  recoveries  and  three  deaths. 


18 


ABDOMEN.    CONTUSION.    TEEATMENT. 


expectant  treatment  having  been  em- 
ployed. Wagner  (Deutsche  Zeit.  f.  Chir., 
B.  34,  p.  98,  '93). 

Five  cases  of  primary  nephrectomy 
with  one  death,  a  mortality  of  20  per 
cent.;  and  thirteen  cases  of  secondary 
nephrectomy  with  five  deaths,  a  mor- 
tality of  38.5  per  cent.,  showing  that 
secondary  nephrectomy  is  nearly  twice 
as  fatal  as  primary. 

As  to  the  route  of  the  operation;  of 
three  cases  of  abdominal  nephrectomy, 
one  died,  a  mortality  of  33.3  per  cent.; 
and  fourteen  of  lumbar  nephrectomy,  of 
vphich  four  died,  a  mortality  of  28.6  per 
cent.  W.  W.  Keen  (Annals  of  Surg., 
Aug.,  '96). 

Bladder.  —  When  a  patient  presents 
the  history  of  a  severe  abdominal  con- 
tusion or  crushing,  followed  by  inability 
to  micturate,  the  catheter  should  at  once 
be  used. 

Most  important  signs  of  vesical  rupt- 
ure: a  peculiar  pain  felt  at  the  time  of 
the  injury;  chilling  of  the  surface  of  the 
body,  which  persists  for  some  time:  an 
urgent  desire  to  micturate,  which  the 
patient  cannot  satisfy;  the  absence  of 
any  vesical  swelling  above  and  behind 
the  pubes,  and  also  the  absence  or  the 
presence,  but  in  verj'  small  quantity,  of 
urine  in  the  bladder.  Catheterizing, 
though  valuable,  ought  not  to  be  prac- 
ticed except  with  very  gieat  caution. 
Sieur  (Arch.  Gen.  de  Med.,  Feb.,  Mar., 
'94). 

The  presence  of  htematuria  will  indi- 
cate a  lesion  in  the  urinary  tract,  kidney, 
or  bladder.  If  the  urine  withdrawn  is 
observed  to  be  well  mixed  with  blood 
and,  instead  of  red,  it  appear  brown  and 
smoky,  the  lesion  is  probably  one  of  the 
kidney.  If,  on  the  contrary,  the  urine 
be  bright  red,  the  probability  is  that 
the  bladder  has  been  torn.  In  the  latter 
condition  the  diagnosis  may  also  be  as- 
sisted by  the  quantity  of  fluid  passed  at 
a  given  time.  If,  when  the  catheter  is 
introduced  and  after  a  history  marked 
with   shock,   no  urine   is   obtained,   the 


chances  are  that  not  only  the  bladder  has 
been  ruptured,  but  that  the  laceration. 
is  extensive,  the  opening  having  allowed 
the  vesical  fluids  to  escape  into  the  ab- 
dominal cavity.  A  free  flow,  on  the  con- 
trary, would  tend  to  show  that  the  tear, 
if  any  exist,  is  small.  Of  course,  the 
invagination  of  the  intestines  into  the- 
vesical  opening,  or  a  valve-shaped  lacer- 
ation, may  cause  the  same  favorable 
signs  to  exist,  thus  misleading  the  diag- 
nostician. Very  small  lesions  may  be- 
present,  sufficient  to  allow  the  urine  to 
escape,  drop  by  drop,  into  the  surround- 
ing parts.  Detection  of  them  is  very 
difficult,  the  subsequent  complications- 
alone  showing  the  presence  of  extrava- 
sated  fluids. 

The  presence  of  any  tear,  except  very" 
small  ones,  may  also  be  ascertained  by 
injecting  a  weak  boric-acid  solution  into 
the  organ,  through  the  catheter.  If  a. 
rupture  be  present,  the  bladder  will  not 
fill  and  rise  above  the  pubis.  Filtered 
air  may  be  used  for  the  same  purpose, 
but  it  is  less  satisfactory,  owing  to  the- 
danger  of  secondary  collapse. 

Case  in  which  diagnosis  was  estab- 
lished by  inflating  the  bladder  with  air 
forced  in  by  two  or  three  compressions- 
of  the  rubber  ball  of  an  ether-freezing 
microtome.  The  amount  of  air  to  be 
introduced  need  only  be  very  small,  and 
only  moderate  pressure  is  required  for 
the  inflation. 

The  introduction  of  air  through  the- 
rent  into  the  abdominal  cavity,  even  in 
small  quantity,  v.as  attended  by  a  pro- 
found disturbance  in  the  patient's  gen- 
eral condition,  which  passed  off  on  open- 
ing the  abdomen  and  allowing  the  free- 
air  to  escape.  The  method  should  not  be 
applied  till  the  patient  is  on  the  operat- 
ing-table, so  that,  should  the  collapse 
threaten  life,  the  abdomen  could  be 
opened  at  once.  W.  J.  Walsham  (Univ. 
Med.  Jour.,  July,  '95). 
The  urine  may  have  passed  into  the 
prevesical  connective  tissue  outside  the- 


ABDOMEN.     CONTUSION.     TREATMENT. 


19 


peritoneiTm,  or  the  vesico-rectal  or  ves- 
ico-uterine  space,  owing  to  a  rupture 
in  these  locations.  This  constitutes  the 
extraperitoneal  lesion.  Cellulitis  and 
sloughing  rapidly  ensue  without  subse- 
quent involvement  of  any  organ  in  the 
neighborhood  of  the  lesion,  the  vagina, 
the  rectum,  etc.,  the  patient  dying  from 
septicfemia. 

Two  eases  of  unconiplieated  intraperi- 
toneal  rupture   of   the   bladder.      Death 
probably   due    to   the    absorption    of    the 
urine  by  the  peritoneum  and  to  its  con- 
tinuous accumulation  in  the  blood.     In 
both  cases  the  rupture  was  situated  on 
the  posterior  wall.     There  were  no  signs 
of  acute  peritonitis  in  either  case.     The 
patients   lived    probably    five   and    three 
days,    respectively^    after    the    accident. 
Joseph  Coats  (Brit.  Med.  .Jour.,  .July  21, 
'94). 
To  ascertain  whether  a  tear  be  extra- 
peritoneal or  not,  a  measured  quantity 
of  a  weak  boric-acid  solution  is  injected 
through  the  catheter.   If  the  full  amount 
is  not  recovered,  the  chances  are  that  the 
rupture  is  extraperitoneal. 

In   investigating   a    suspected    case   of 
rupture  the  greatest  care  should  be  taken 
to  keep  the  bladder  aseptic:    so  that,  in 
case  there  is  a  rent,  germs  cannot  spread 
into  the  tissues,  and  especially  into  the 
peritoneal   cavity.     In   making  the   test 
also    of    injecting    fluids    in     measured 
amounts,  and  then  observing  whether  the 
same  amount  is  voided,  care  should  be 
taken  not  to  distend   the  bladder  more 
than  very  moderately,  lest  a  partial  rupt- 
ure  be   converted   into   a   complete  one. 
H.  Aue   (Deutsche  Zeit.  f.  Chir.,  p.  351, 
'92). 
Eupture    into    the    peritoneal    cavity, 
the  intraperitoneal  form  of  lesion,  is  less 
urgent  as  far  as  symptoms  go.    One,  and 
even  two,  days  may  elapse  before  active 
symptoms  appear;    but,  when  they  do, 
rapid  progress  toward  a  fatal  issue  from 
general  peritonitis  is  the  rule. 

Uncomplicated  contusion  of  the  blad- 
der readily  yields  to  a  few  days'  rest, 


the  application  of  ice,  and  general  symp- 
tomatic treatment.  When,  however, 
there  is  cause  for  suspecting  a  rupture 
from  the  nature  of  the  accident  or  the 
violence  of  the  blow,  the  catheter  should 
at  once  be  introduced.  The  presence  of 
blood  renders  operative  interference  im- 
perative. After  the  rectum  has  been 
distended  with  a  rectal  bag  an  incision 
three  inches  long  is  made  in  the  middle 
line  of  the  hypogastrium,  beginning  half 
an  inch  below  the  upper  edge  of  the 
pubes,  as  in  suprapubic  lithotomy. 

It  is  best  to  first  open  the  prevesical 
space,  when  it  can  be  determined 
whether  the  rupture  is  extraperitoneal, 
and,  if  so,  the  necessary  treatment  to  be 
carried  out.  If  the  rupture  is  found 
intraperitoneal,  the  abdominal  incision 
is  carried  upward  and  the  peritoneal 
cavity  is  opened,  when  the  rent  is  located 
and  properly  disposed  of.  John  B. 
Deaver  (Univ.  Med.  Mag.,  July,  '96). 

The  peritoneum  is  then  carefully 
rolled  up,  along  with  the  prevesical  fat. 
The  bladder  being  thus  exposed,  search 
for  the  rupture  is  the  next  step.  The 
rent  is  usually  found  along  the  poste- 
rior surface  vertically  down  from  the 
urachus;  frequently  an  extravasation 
of  blood  and  urine  indicates  the  spot. 
Occasionally,  however,  considerable  diffi- 
culty is  experienced,  and  opening  of  the 
organ  is  necessary  so  as  to  permit  the 
introduction  of  the  finger,  and  thus 
allow  of  exploration  of  its  inner  surface. 

The  rupture  may  be  extraperitoneal 
or  intraperitoneal.  If  an  intraperitoneal 
laceration  is  found,  the  incision  should 
be  extended  upward,  the  peritoneal  cav- 
ity opened,  and  the  cystic  wound  closed 
with  fine  silk  by  means  of  Lembert 
sutures,  one-eighth  of  an  inch  apart, 
including  only  the  peritoneal  and  mus- 
cular coats.  The  mucoits  membrane  of 
the  bladder  should  be  respected.  Impor- 
tant, in  this  connection,  is  the  neces- 


20 


ABDOMEN.     WOUNDS. 


sity  of  ascertaining  that  the  sutures  will 
hold;  this  may  be  done  by  distending 
the  bladder  with  a  lukewarm  milk  or  an 
alkaline  solution. 

Of  the   28   cases   recorded   by   various 
operators,  11  recovered  and  17  died.     Of 
the    11    that   recovered,   in    only    1    was 
peritonitis  present  at  the  time  of  opera- 
tion,  while,   conversely,   of   the    17   that 
died,  in  8,  and  probably  in  9,  peritonitis 
had  already  set  in.    The  causes  of  death 
in  the   8   cases   in   which   there   \^as   no 
peritonitis  at  the  time  of  operation  were : 
in  5,  shock  or  hsemorrliage  or  the  two 
combined,  and  in  3  peritonitis,  the  peri- 
tonitis in  2  out  of  the  3  being  due  to 
leakage  of  the  rent  or  giving  way  of  a 
suture.     In  no  fewer  than  4  out  of  the 
28  cases  was  the  bladder  found,  at  the 
post-mortem  examination,  to  leak.     The 
importance  of  testing  the  competency  of 
the  bladder  by  injecting  milk  or  other 
bland  and  easily  detectable  fluid  could 
not,    therefore,    be    too    strongly    urged. 
W.  J.  Walsham  (Univ.  Med.  Jour.,  July, 
'95). 
The  abdominal  cavity  is  then  carefully 
irrigated  and  closed,  leaving  a  drain  if 
there  is  any  possibility  that  fluids  will 
accumulate  in  any   of  the   surrounding 
tissues. 
Wounds. 

Wounds  of  the  abdomen  may  be  non- 
penetrating, when  the  abdominal  walls 
alone  are  injured,  and  penetrating,  when 
the  peritoneum  is  included  in  the  lesion, 
irrespective  of  the  instrument  (pistol, 
knife,  etc.)  with  which  the  lesion  is  pro- 
duced. 

Non-penetrating  Wounds. 
Non-penetrating   wounds   are   usually 
due  to  pointed  cutting  or  blunt  instru- 
ments. 

The  lesions  caused  by  a  pointed  in- 
strument, involving  the  skin  and  muscles 
only,  are  usually  very  slight.  With  due 
aseptic  precautions  careful  exploration 
of  the  wound  with  the  finger  may  be  re- 
sorted to  if  the  visceral  examination  do 


not  suffice.  Probes  had  better  not  be 
used,  lest  the  wound  be  transformed  into 
a  penetrating  one. 

Lesions  caused  by  cutting  instruments 
(knives,  swords,  etc.)  vary  in  importance 
according  to  their  depth  and  length. 
When  the  muscles  are  cut,  the  support 
for  the  abdominal  organs  is  compro-. 
mised,  and  ventral  hernia  may  follow, 
unless  great  care  be  taken  when  the 
wound  is  closed. 

Lesions  caused  by  blunt  bodies  (such 
as  shot,  glancing  bullets,  and  fragments 
of  shells,  etc.)  are  usually  attended  by 
symptoms  of  contusions  corresponding 
in  intensity  with  the  force  of  the  blow. 
Severe  laceration  of  the  abdominal  tis- 
sues may  thus  be  caused  and  death  occur 
from  intestinal  lesions. 

The  hfemorrhage  attending  these  vari- 
ous kinds  of  wounds  is  usually  slight. 
There  is  considerable  ecchymosis,  but 
this  soon  disappears.  Occasionally  shots 
or  bullets  become  imbedded  in  the  ab- 
dominal tissues. 

Treatment. — After  carefully  arresting 
bleeding,  cleansing,  and  disinfecting  the 
wound,  the  tissues  are  united.  In  deep 
incised  wounds  the  prevention  of  ventral 
hernia  should  be  borne  in  mind,  and  the 
cut  muscular  tissues  brought  accurately 
together  by  means  of  catgut  sutures. 
This  being  done,  silk  sutures  are  also 
introdiTced  and  brought  out  to  the  sur- 
face, thus  including  the  muscles  and 
skin.  Capillary  drains  are  alone  to  be 
used,  if  drainage  is  at  all  necessary, 
larger  drains  affording  opportunity  for 
the  formation  of  a  ventral  hernia.  The 
abdomen  should  be  supported  by  means 
of  a  bandage  applied  over  the  dressing 
and  the  patient  kept  in  bed  until  com- 
plete repair  of  the  wound  has  taken 
place;  from  two  to  five  weeks,  as  a  rule. 
The  bandage  should  be  carried  long  after 
recovery,  and  the  patient  be  warned  of 


ABDOJIEN.     I'KNETKATING  WOUNDS.     SYMPTOJIS. 


21 


the  danger  he  might  incur  by  violent 
movement  or  strain. 

Penetrating  Wounds. 

The  softness  of  the  tissues  of  the 
abdominal  parietes  causes  them  to  be 
easily  penetrated,  and  the  organs  within 
the  cavity  are  all  vulnerable  for  the  same 
reason.  The  interstices  between  them 
occasionally  allow  the  harmless  passage 
of  a  weapon  or  bullet,  but  such  cases 
are  extremely  rare,  only  nine  such  cases 
having  been  recorded  during  the  Ee- 
bellion. 

The  missile  may  graze  the  peritoneum 
and  barely  miss  it  along  with  the  deeper 
organs.  Unfortunately  wounds  causing 
laceration  of  one  or  more  of  the  abdom- 
inal viscera  are  the  most  frequent,  and 
their  fatality  is  proverbial  unless  a  timely 
diagnosis  allow  of  prompt  protective 
measures. 

As  is  the  case  in  contusions,  the  di- 
rection from  which  the  missile  or  stab 
comes  is  of  great  importance.  A  bullet 
arriving  from  the  side  and  striking  near 
the  linea  alba  would  probably  create  a 
button-hole  wound  or  bury  itself  in  the 
abdominal  walls.  A  bullet  coming  from 
the  front,  on  the  contrary,  would  most 
probably  perforate  the  organs  in  its 
axial  line  of  flight.  If  the  bullet  has 
passed  through  the  body  an  imaginary 
line  between  the  entrance  and  exit  will 
probably  indicate  the  organs  injured, 
including,  of  course,  the  peritoneum. 
Here  again,  however,  the  spinal  column 
may  cause  deviation  when  the  initial 
velocity  of  the  bullet  is  small,  and  a 
deceptive  line  of  injury  furnished.  To 
positively  determine  the  course  of  a 
bullet  is  difficult  in  many  cases. 

In  stab  wounds  the  opening  is  fre- 
quently of  a  sufficient  size  to  permit  pro- 
lapse of  the  omentum:  an  evident  proof 
that  the  abdominal  cavity  has  been 
penetrated.    This  rarely  occurs  in  bullet 


wovmds  unless  a  large  projectile,  or  a 
bullet  coming  from  either  side  of  victim, 
have  caused  comparatively  large  solution 
of  continuity  of  the  tissues.  Prolapse 
of  the  omentum  is  most  frequently  ob- 
served in  lesions  of  the  left  side.  Coils 
of  the  small  intestines  are  also  frequently 
prolapsed  and,  in  rare  cases,  the  stomach, 
the  liver,  or  the  spleen  have  appeared 
between  the  lips  of  the  wound. 

Symptoms. — As  is  the  case  after  con- 
tusion, penetrating  wounds  of  the  ab- 
domen may  give  rise  to  no  symptoms 
capable  of  affording  any  reliable  clue  to 
the  extent  of  the  internal  injuries.  Pro- 
found shock  may  be  present  and  no 
serious  lesion  exist. 

Case  of  a  man  brought  into  one  of  the 
surgical  wards  with  an  external  wound. 
He  was  lifted  to  bed  absolutely  helpless 
and  a  serious  gunshot  wound  of  the 
abdomen  suspected  from  gravity  of 
symptoms.  The  bullet  found  in  the  leg 
of  his  drawers.  The  patient  was  unable 
to  get  out  of  bed  for  hours.  A.  B.  Miles 
(Southern  Surg,  and  Gynec.  Trans.,  vol. 
vi,  p.  183,  "94). 

Severely  injured  individuals  may,  on 
the  contrary,  present  no  acute  symptoms 
and,  perhaps,  walk  or  ride  a  considerable 
distance  before  showing  noticeable  evi- 
dence of  their  condition. 

Case  of  15-year  old  boy  who  sustained 
penetrating  wound  of  the  abdomen,  with 
protrusion  of  more  than  a  foot  of  intes- 
tine, by  being  horned  by  a  bull.  There 
was  total  absence  of  shock,  although  the 
accident  occurred  si.x  hours  before  the 
boy  came  under  observation,  and  the  pa- 
tient was  brought  in  a  country-cart  over 
five  miles  of  very  hard  road.  George 
Bidie  (Brit.  Med.  Jour.,  Sept.  24,  '98). 

Profuse  hfemorrhage  alone  gives  rise 
to  symptoms  denoting  a  grave  lesion: 
rapidly  progressive  exsanguination  or 
acute  anfemia;  nausea  or  vomiting;  weak, 
rapid,  and  sometimes  irregular  pulse; 
dilated    pupils;    cold    sweats;    yawning, 


22 


ABDOMEN.     PENETRATING  WOUNDS.     DIAGNOSIS. 


ending  in  convulsions  and  coma.  Shock 
is  likely  to  be  progressive  in  these  cases. 
Fatal  cases  of  marked  laceration  of 
liver  and  bowel  in  which  there  was 
neither  shock,  haemorrhage,  nor  high 
pulse.  W.  L.  Robinson  (Jour.  Amer. 
Med.  Assoc,  Dec.  15,  '94). 

If  the   shock   is   progressive   it  means 
internal  haemorrhage.     When   a   patient 
is    first    seen     he    may    be    profoundly 
shocked  and  not  be  much  disturbed,  but, 
if  he  continues  to  become  more  shocked, 
it    means    hsemorrhage.      Shock    at    the 
time   of   injury   does   not  mean   haemor- 
rhage, but  later  on  it  does.     L.  McLane 
Tiffany     (Pacific    Record    of    Med.    and 
Surg.,  Feb.  15,  '96). 
The  only  symptoms  that  are  present 
in  practically   all   cases   are   pallor   and 
vomiting:    the  accompaniments  of  any 
severe  blow  on  the  abdomen,  and  there- 
fore of  no  value  whatever  as  differential 
signs.    The  temperature  is  of  no  assist- 
ance in  these  cases. 

Cases  showing  that  with  normal  tem- 
perature a  fatal  injury  (without  opera- 
tion) may  be  present,  while,  after  oper- 
ation, a  subnormal  temperature  may  be 
expected;    95°  F.  has  been  recorded.     L. 
M.  Tiffany  (Amer.  Jour.  Med.  Sci.,  May, 
'96). 
Diagnosis.  —  On     general     principles 
dangerous   complications  are   to   be   ex- 
pected   when    marked    shock,    nausea, 
vomiting,     hiccough,     anxiety,     intense 
thirst    (indicating    a    probable    involve- 
ment of  the  peritoneum),  and  insomnia 
are  present.     Besides  these  indications 
there  are  others  peculiar  to  each  organ 
which   greatly   assist   in   establishing   at 
least  an  approximately  certain  diagnosis. 
The  absence  of  liver-dullness  is  of  less 
significance  than  is  usually  believed,  but 
the  disappearance  of  liver-dullness  is  of 
more  value.    The  most  important  symp- 
toms in  personal  cases  were  tension  of 
the  abdominal  muscles,  local  meteorisms, 
and  dullness  in  the  region  of  the  wound. 
The   general    symptoms   were   those   of 
peritonitis.      Petersen    (Miincliener   raed. 
Woch.,  Apr.  9,  1901). 


Intestines. — According  to  Senn,  bul- 
lets striking  the  abdomen  antero-posteri- 
orly  rarely  cause  more  than  four  per- 
forations, while  oblique  or  transverse 
shots  are  likely  to  produce  a  much  larger 
number  of  lesions:  from  fourteen  to 
sixteen.  On  general  principles,  however, 
a  penetrating  wound  may  always  be  con- 
sidered as  having  caused  a  lesion  of  the 
intestines. 

The  most  important  symptom  is  the 
escape  of  intestinal  gases  and  more  or 
less  fluid  substances  through  the  wound. 
The  mere  presence  of  emphysema  around 
the  wound  is  of  no  value,  however,  since 
air  is  generally  forced  into  the  wound  by 
the  bullet. 

Some  years  ago  Senn  recommended 
the  insufflation  of  hydrogen-gas  to  ascer- 
tain the  presence  of  intestinal  perfora- 
tion. Having  introduced  it  into  the 
rectum,  he  ascertained  whether  it  es- 
caped into  the  peritoneal  cavity  and  thus 
passed  out  through  the  parietal  opening. 
The  method  was  found  unreliable,  how- 
ever, and  has  been  pretty  generally  dis- 
carded. 

Case  in  wliieh  the  absence  of  intestinal 
pei'foration  was  established  by  ether  in- 
flation   of    the    intestines.      The    bowels 
were  inflated  with  ether,  which  escaped 
from  the  mouth.     The  peritoneal  cavity 
was  opened,  and  the  ball  was  found  to 
have  passed  above  the  liver,  injuring  the 
diaphragm,    and    burying    itself    in    the 
tissues    behind.      The    blood-clots    were 
removed  and  the  abdomen  closed.     The 
inflation  of  the  intestines  caused  a  sense 
of  fullness,  but  no  other  discomfort.    The 
patient    made    an    uneventful    recovery. 
E.  M.  Sutton   (Jour.  Amer.  Med.  Assoc, 
Dec.  30,  '99). 
Free    hajmorrhage    from    the    wound 
tends   to   indicate   an   intestinal   lesion; 
if  the  stools  also  contain  blood  the  diag- 
nosis may  be  considered  as  certain. 

In  small  wounds  of  the  bowel  the 
mucous  membrane  pouts  out  and  closes 
the  orifice;    as  soon  as  peristalsis  occurs 


ABDOMEN.     PENETRATING  WOUNDS.     DIAGNOSIS. 


23 


it  is  drawn  in,  and  there  may  be  an 
escape  of  a  small  fseeal  mass.  A  large 
amount  of  fseeal  matter  may  thus  be 
extruded  through  a  small  opening. 
Klemm  (Deutsche  Zeit.  f.  Chir.,  B.  ,33, 
H.  2,  3,  '92). 

In  wounds  of  the  intestines  of  very 
short  extent  (the  most  frequently  met 
with)  the  mucous  membrane  makes  a 
hernia  between  the  lips  of  the  wound, 
obstructing  and  thus  preventing  the 
flow  of  the  faecal  matter,  and  in  conse- 
quence avoiding  the  onset  of  peritonitis. 
The  gas  would  pass  through  the  wound, 
facilitating  at  once  the  passage  of  these 
materials.  Tobias  Nunez  (Brit.  Med. 
Jour.,  Oct.  9,  '97). 

Probes  have  been  discarded  in  pene- 
trating wounds,  owing  to  the  irregular 
course  followed  by  the  bullet  in  many 
cases  and  the  danger  of  creating  a  false 
passage.  Digital  exploration  of  small 
wounds  furnish  but  little  information, 
while  in  bullet  wounds  there  is  danger 
of  pushing  into  the  peritoneal  cavity 
what  foreign  substances  may  happen  to 
be  present. 

The  majority  of  surgeons  now  favor 
enlargement  by  an  incision  at  least  two 
inches  in  length,  intersecting  the  bullet 
or  incised  wound.  Layer  after  layer  of 
tissue  is  carefully  dissected  on  each  side 
of  the  track,  the  walls  of  which,  in  gun- 
shot wounds,  are  usually  darker  than  the 
normal  tissues,  owing  to  contact  with  the 
lead  or  powder-products  of  combustion. 
Using  the  grooved  director  to  divide  the 
tissues  and  the  haemostatic  forceps  to 
grasp  any  bleeding  vessel,  the  perito- 
neum is  finally  reached,  when  the  cer- 
tainty that  a  penetrating  wound  is 
present  or  not  may  be  established.  If 
practiced  with  strict  aseptic  precautions, 
this  procedure  does  not  expose  the  pa- 
tient. 

Study  of  fifty-six  cases  showing  that 
proof  of  penetration  through  peritoneum 
should  be  sought  by  enlargement  and 
careful  investigation  of  original  wound. 


Penetration  having  been  found,  imme- 
diate enlargement  of  the  wound  shouli 
be  made.  C.  L.  Seudder  (Boston  Med. 
and  Surg.  Jour.,  July  25,  '95). 

Stomach. — Hajmatemesis  is  a  frequent 
symptom  of  penetrating  wound  of  this 
organ  and  a  much  more  valuable  one 
than  in  contusion,  since,  in  the  latter, 
a  slight  laceration  of  the  mucous  mem- 
brane may  produce  it.  The  blood  may 
be  pure,  but  in  the  majority  of  instances 
it  is  mixed  with  partially-digested  ali- 
mentary semiliquid  material.  If  the 
wound  is  sufficiently  large  to  allow  the 
contents  to  escape  through  it  the  nature 
of  the  injury  is,  of  course,  clear,  but  an 
important  complication  is  to  be  appre- 
hended: extravasation  into  the  perito- 
neal cavity  capable  of  causing  peritonitis. 
If  this  is  circumscribed,  adhesions  are 
formed  and  the  patient  recovers.  Fre- 
quently, however,  general  peritonitis 
follows,  ending  in  death.  Hence  the 
importance  of  an  early  recognition  of 
extravasation. 

Besides  hasmatemesis  and  the  presence 
of  gastric  fluids,  there  are  usually  present 
in  such  injuries  the  marked  symptoms 
witnessed  in  cases  of  contusion:  rapidly 
progressive  anaemia,  pallor,  fluttering 
pulse,  etc. 

Liver.  —  A  wound  of  the  liver  gives 
rise  to  all  the  symptoms  observed  when 
a  contusion  has  caused  laceration  of  the 
organ.  Intermittent  pain,  radiating  in 
various  directions,  especially  toward  the 
shoulder,  if  the  convex  portion  of  the 
organ  is  torn,  and  in  the  direction  of  the 
waist,  if  the  concave  or  inferior  portion 
of  the  organ  is  the  seat  of  injury.  There 
is  marked  pallor,  superficial  itching,  and, 
later  on,  jaundice.  The  stools  may  be 
clay-colored,  thus  indicating  the  absence 
of  bile. 

The  hfemorrhage  varies  in  these  cases 
according  to  the  cause  of  the  lesion;  one 


24 


ABDOMEN.     PENETRATING  WOUNDS.     DIAGNOSIS. 


caused  by  a  bullet  is  prone  to  be  accom- 
panied by  considerable  and  frequently 
fatal  bleeding.  Stab  wounds,  when  the 
weapon  is  not  large,  do  not  give  rise  to 
considerable  hsemorrhage.  A  copious 
flow  of  blood  from  a  wound  in  the 
hepatic  region  indicates  that  the  liver  is 
involved.  The  flow  of  bile  through  the 
wound  is  a  valuable  sign,  but  it  is  seldom 
that  this  secretion  can  be  obtained  alone, 
blood  being  usually  mixed  with  it. 

Spleen. — In  cases  in  which  the  spleen 
is  wounded  the  diagnosis  can  easily  be  es- 
tablished by  the  location  of  the  external 
opening  and  the  direction  of  the  track. 


Perforating  gunshot  v>  ound  of  the  kidney. 
(M.  E.  Richardson.) 

(Annals  of  Surgery.) 

As  is  the  case  in  contusion,  there  is 
marked  local  pain  and  profuse  bleeding, 
which,  if  the  organ  is  greatly  lacerated, 
may  soon  prove  fatal.  This  is  apt  to 
occur  after  gunshot  wounds  at  close 
range,  the  organ  under  such  circum- 
stances becoming  pulpified.  Puncture 
wounds  are  less  likely  to  produce  fatal 
hsemorrhage. 

Kidneys.  —  The  symptoms  frequently 
accompanying  wounds  of  the  abdominal 
organs,  extreme  pallor,  weak  pulse,  cold 
extremities,  nausea,  and  vomiting  are  apt 
to  be  most  marked  when,  besides  the 
organ  itself,  the  peritoneum  has  been 
pierced. 


A  wound  of  the  kidney  gives  rise  to 
severe  pain  in  the  majority  of  cases,  but 
this  symptom  may  be  absent.  As  in 
cases  of  laceration,  the  pain  radiates  in 
various  directions,  especially  in  the  di- 
rection of  the  external  genital  organs. 
The  testicle  of  the  corresponding  side, 
besides  being  the  seat  of  considerable 
suffering,  is  frequently  raised  by  spas- 
modic contractions  of  the  scrotum. 

At  first  a  small  quantity  of  bloody 
urine  may  be  passed,  but  this  is  often 
followed  by  vesical  tenesmus  and  com- 
plete retention,  due  to  the  presence  of 
clots  in  the  bladder. 

Much  information  is  sometimes  ob- 
tained by  a  close  examination  of  the 
wound  of  exit.  If  the  track  of  the  bullet 
be  antero-posterior  and  the  missile  have 
entered  from  the  front  and  penetrated 
the  kidney,  the  exit  wound  will  be  found 
in  the  lumbar  region.  It  is  frequently 
found  in  this  situation  to  contain  urine, 
a  positive  indication  that  the  organ  or 
its  annex,  the  ureter,  has  been  wounded. 

If  the  wound  of  entrance  be  in  the 
back,  its  location  over  the  site  of  the  kid- 
ney may  suggest  a  lesion  of  the  latter; 
but  the  urine  test  will  only  be  of  value  if 
the  projectile  only  penetrate  the  kidney 
without  perforating  it.  If  it  penetrate 
the  organ,  the  extravasation  will  take 
place  into  the  peritoneal  cavity.  The 
same  will  be  the  case  if  the  missile  enter 
from  the  front  without  going  through 
the  organ.  Bullets  buried  in  the  renal 
parenchyma  either  become  encysted  or 
cause  abscesses,  and  pass  out  through 
the  ureters  or  into  the  adjoining  parts. 

Case  of  gunshot  wound  of  the  kidney 
made  evident  by  the  appearance  of  urine 
saturating  the  dressing  in  the  lumbar 
region.  The  amount  of  urine  on  the 
dressing  gradually  decreased,  and  after 
about  six  weeks  the  sinus  had  closed. 
William  F.  Barry  (Med.  Record,  Mar. 
24,  1900). 


ABDOMEN.    PENETRATING  WOUNDS.    PROGNOSIS. 


Bladder. — The  symptoms  vary  accord- 
ing to  the  location  of  the  wound.  A 
perforation  between  the  symphysis  and 
the  peritonenm  above  does  not  give  rise 
to  general  symptoms;  whereas  shock, 
pallor,  weak  pnlse,  vomiting,  etc.,  may 
be  much  marked  when  the  peritoneum 
is  involved  in  the  injury.  In  all  cases, 
however,  severe  pain  is  experienced  at 
the  site  of  the  lesion  and  radiating  to  the 
thighs  and  testicles. 

The  passage  of  urine  soon  becomes 
very  difficult  and  spasmodic.  It  may  be 
voided,  drop  by  drop,  for  a  long  while, 
notwithstanding  the  efforts  of  the  pa- 
tient, then  suddenly  gush  out  for  a  few 
moments  and  again  flow  slowly.  This 
symptom  may  be  due  to  accumulation 
of  clots  or  to  spasm  of  the  urethra.  If 
the  catheter  is  passed,  hsematuria  be- 
comes evident  when  the  bladder  has  been 
penetrated:   a  characteristic  sign. 

As  in  the  case  of  rupture  due  to 
contusion,  infiltration  may  take  place 
through  the  wound  into  the  neighboring 
tissues;  any  obstacle  to  the  free  passage 
of  urine  greatly  encourages  this.  Hence 
the  necessity,  in  all  bladder  lesions,  of 
keeping  the  organ  as  free  as  possible  by 
the  frequent  use  of  the  catheter. 

Prognosis. — The  statistics  so  far  pub- 
lished differ  so  widely  that  it  is  difficult 
to  reach  a  definite  conclusion.  It  is  cer- 
tain, however,  that  gimshot  wounds  are 
more  frequently  fatal  than  stab  wounds, 
but  that  stab  wounds,  in  which  the  peri- 
toneum is  penetrated,  are  fully  as  fatal 
as  gunshot  wounds.'' 

Intraperitoneal  wounds  of  the  bladder 
are  uniformly  fatal,  while  extraperito- 
neal wounds  gave  a  mortality  of  only  15 
per  cent.  Gunshot  wounds  of  the  kidney 
are  attended  with  a  death-rate  of  44  per 
cent.  In  gunshot  wounds  of  the  liver 
the  mortality  is  26.8  per  cent.  Wounds 
of  the  spleen  are  difficult  to  diagnose; 
mortality    65    per    cent.      Wounds    of 


spinal  cord  in  the  lumbar  region  result 
fatally.  Mortality  of  wounds  of  the 
pelvic  bones  also  very  high.  Seliger 
(Prager  med.  Woch.,  '92). 

Statistics  collected  by  various  writers, 
showing  the  mortality  to  range  from 
65.6  per  cent,  to  70.67  per  cent.  Shock 
is  one  of  the  chief  causes  of  these  re- 
sults. Conner  (Jour.  Amer.  Med.  Assoc., 
Sept.  16,  '93). 

Immediate  operation  is  the  best  and 
wisest  course  to  pursue  in  perforated, 
punctui'ed,  and  gunshot  wounds  of  the 
abdomen.  This  is  the  rule  which  is  fol- 
lowed in  the  University  of  Munich. 
Seven  gunshot  wounds  treated  with  a 
mortality  of  58  per  cent.,  and  22  stab 
wounds,  with  a  mortality  of  18.1  per 
cent.  Series  of  30  eases  treated  by  con- 
servative methods  between  1870  and 
1890,  the  mortality  having  been  46.6  per 
cent.  Paul  Ziegler  (Miinch.  med.  Woch., 
Mar.  8,  '98). 

In  253  cases  of  gunshot  injuries  of  the 
abdomen  the  total  mortality  was  about 
52  per  cent.;  in  28  of  the  133  fatal  cases 
unsecured  perforations  or  haemorrhage 
was  found;  peritonitis  at  the  operation 
was  found  in  11  of  the  cases  that  recov- 
ered, showing  that  about  5  per  cent,  of 
such  cases  recover  even  if  this  dangerous 
complication  is  present.  H.  H.  Grant 
(Jour.  Amer.  Med.  Assoc,  Mar.  17,  1900). 

The  kind  of  weapon  inflicting  the  in- 
jury plays  an  important  role  in  this  con- 
nection. A  triple-edged  bayonet  is  more 
likely  to  produce  a  serious  laceration 
than  a  fiat  blade.  Again,  wounds  caused 
by  small  weapons,  such  as  a  Mobert  rifle, 
for  instance,  would  hardly  produce  le- 
sions to  be  compared  to  the  old  Enfield 
or  Minie  rifles,  which  sometimes  caused 
a  large  portion  of  an  organ  to  protrude 
through  a  wound  of  exit  the  size  of  an 
apple. 

Portions  of  the  solid  viscera  are  some- 
times cut  off  or  shot  off,  leaving  a  gap- 
ing tear,  which  greatly  compromises  the 
issue.  Again,  as  is  often  the  case  with 
the  liver,  the  bullet,  or  any  foreign  ma- 
terial dragged  in  by  the  latter,  may  lead 


26 


ABDOMEN.     PENETRATING  WOUNDS.     PROGNOSIS. 


to   complications   which   greatly   reduce 
the  chances  of  recovery. 

An  important  factor  is  the  time  elaps- 
ing between  the  receipt  of  the  injury 
and  that  at  which  competent  treatment 
is  applied  in  mild  cases.  This  is  espe- 
cially true  as  regards  the  early  utiliza- 
tion of  surgical  measures  when  these 
become  necessary.  The  sooner  these  are 
instituted,  the  more  favorable  the  prog- 
nosis, especially  during  the  first  ten 
hours. 

Statistics  of  154  laparotomies  for  gun- 
shot wounds:  Operation  five  hours  after 
traumatism;  mortality,  52.7  per  cent. 
Operation  ten  hours  after  traumatism; 
mortality,  74  per  cent.  Operation  twenty 
hours  after  traumatism;  mortality,  73.9 
per  cent.  Operation  after  twenty  hours 
after  traumatism;  mortality,  78.2  per 
cent.  Haemorrhage  kills  early,  if  at  all. 
Edouard  Adler  (Jour,  de  Med.  et  de 
Chir.  Prat.,  Sept.  25,  '92). 

Intestines.  —  The  prognosis  depends 
greatly  upon  the  nature  of  the  lesions. 
Stab  wounds  opening  the  intestine 
lengthwise,  if  small,  often  heal  of  their 
own  accord;  transverse  wounds  are  more 
serious,  while  complete  section  of  the 
bowel  is  a  very  dangerous  complication. 
Gunshot  wounds  show  a  great  fatality. 
Prior  to  the  introduction  of  antiseptic 
surgery  the  mortality  exceeded  90  per 
cent.;  since  then,  the  mortality  has  been 
decreased  to  43  per  cent,  in  cases  oper- 
ated during  the  first  twelve  hours.  When 
all  surgeons  will  handle  the  intestines 
with  gentleness,  operate  quickly,  and 
otherwise  reduce  the  chances  of  shock, 
it  is  probable  that  the  prognosis  will  be 
greatly  improved.  Perforations  of  the 
descending  colon  and  sigmoid  flexure 
are  seldom  fatal;  those  of  the  transverse 
colon  give  a  worse  prognosis,  by  the  for- 
mation of  fistulas,  adhesions,  and  abnor- 
mal communications.  Again,  diathetic 
conditions  may  compromise  recovery. 


Notwithstanding  great  injury  and 
other  conditions  greatly  reducing  th>'' 
chances  of  recovery,  recoveries  are  occa- 
sionally obtained. 

The  omentum.,  although  it  does  not 
contain  unstriped  or  striped  muscular 
tissue,  has  power  of  mobility,  and  applies 
itself  over  lesions  that  may  occur  in  the 
cavity  of  the  peritoneum.  Thanks  to  the 
omentum,  aseptic  surgical  wounds  of  the 
ureter,  bile-duets,  etc.,  can  be  left  to  heal 
without  sutures,  since  it  practically  walls 
in  the  wound.  Millan  (Gaz.  des  Hop., 
July  1,  '99). 

Case   of   abdominal   injury   caused   by 
the  horn  of  rhinoceros  in  which  a  por- 
tion   of    several    knuckles    of    gut    pro- 
truded through  the  opening,  two  inches 
above  Poupart's  ligament.     The  gut  was 
cleansed  and  returned  and  the  parietal 
peritoneum,   skin,  and  superficial   fascia 
then  closed  by  different  sets  of  sutures. 
In  eleven  days  was  up  and  around.     E. 
W.   Waters    (Brit.   Med.   Jour.,  Nov.   3, 
1900). 
Stomach.  —  Uncomplicated  wounds  of 
this    organ    frequently    yield    without 
trouble  when  the  bullet,  blade,  or  other 
instrument   causing   the   perforation   is 
small,    especially    if    the    stomach    was 
empty  at  the  time  the  injury  was  in- 
flicted.    The  mucous  membrane  bulges 
out  and  forms  a  plug  which  obturates 
the  hole  until  reparative  processes  have 
sealed   the   aperture    on   the   peritoneal 
side.     Complicated  cases,  in  which  the 
lesions  are  extensive,  soon  reach  a  fatal 
issue  if  deprived  of  timely  surgical  inter- 
vention. 

An  individual  shot  when  the  stomach 
is  distended  with  food  will  have  a  better 
chance  to  recover  if  subjected  to  an  oper- 
ation and  the  peritoneal  cavity  washed 
out.  The  probability  is  that  during 
efforts  at  vomiting  part  of  the  contents 
of  stomach  will  be  extruded  through  per- 
forations into  peritoneal  cavity.  R.  B. 
Hall  (Cincinnati  Lancet-Clinic,  May  7, 
'98). 
Liver.  —  The  prognosis  of  wounds  of 
the  liver  depends  mainly  upon  the  com- 


ABDOMEN.     PENETRATING  WOUNDS.     PROGNOSIS. 


27 


plications.  If  the  patient  does  not  die 
from  liEemorrhage  soon  after  the  receipt 
of  the  injury,  he  is  still  exposed  to  the 
results  of  extravasation  into  the  peri- 
toneal cavity,  the  presence  in  the  liver 
■of  a  foreign  body, — the  bullet  and  what 
material  it  may  have  forced  into  the 
wounds, — etc.  Peritonitis,  hepatitis,  and 
•abscess  are,  therefore,  dangers  to  be 
taken  into  consideration.  Hepatitis  and 
-abscess  are  much  less  to  be  feared,  how- 
■ever,  from  stab  wounds,  no  foreign  body 
being  left  behind,  unless,  as  in  dueling, 
the  sword-point  strike  the  spinal  column, 
•causing  the  blade  to  break.  In  such  an 
event,  however,  the  hfemorrhage  woxild 
probably  prove  mortal  very  rapidly. 

As  to  mortality,  the  statistics  of  Edler, 
Mayer,  and  others  show  it  to  average 
.about  50  per  cent.,  including  the  cases 
•attended  by  complications. 

Records   of  272   cases   of  wounds   and 
injuries  of  the  liver.     Cases  divided  into 
those  due  to  direct  and  those  due  to  in- 
direct violence.    Direct  injuries,  164  cases, 
with  58  deaths, — a  mortality  of  35,3  per 
cent.;    indirect,  108  cases,  with  92  deaths, 
— a  mortality  of  85.2  per  cent.     The  for- 
mer class  again  divided  into  two  groups, 
of  54  punctured  or  incised  wounds,  24,  or 
44  per   cent.,  proved  fatal,   while   of   110 
gunshot  wounds  only  34,  or  30  per  cent., 
were  mortal.     Of  the  272  cases,   150,  or 
50.5  per  cent.,  died.     These  figures  cor- 
respond very  closely  with  the  tables  of 
Edler,  which  showed  a  mortality  of  39.1 
per  cent,  after  shot  wounds  and  55  per 
cent,  of  all  cases.     Homer  Gage  and  R. 
Lorini    (Boston    Med.    and    Surg.    Jour., 
Apr.  28,  '92). 
Spleen. — Slight  punctured  wounds  of 
the  spleen  are  not  mortal  unless  compli- 
■cated  with  laceration  of  a  large  artery. 
They    are    sometimes   followed   by    ab- 
scesses  which    heal    after   a    prolonged 
period  in  the  great  majority  of  cases. 
Severe  punctured  wounds  are  dangerous 
in  proportion,  but  if  the  primary  hem- 
orrhage is  not  such  as  to  cause  an  early 


fatal  issue,  the  chances  of  recovery  are 
about  those  of  slight  wounds. 

Gunshot  wounds  are  much  more  seri- 
ous as  a  result  of  rupture  of  the  spleen 
taking  place  itnder  the  concussion,  when 
the  bullet  is  large  and  its  velocity  is 
great.  Fatal  haemorrhage  quickly  en- 
sues. Eupture  of  the  spleen  may  also 
occur  during  convalescence. 

Case  of  wound  in  the  right  hypochon- 
driac region  from  which  the  spleen  was 
protruding.     Wound   had   been   exposed 
to  soiled   clothing  and  a   septic  process 
feared.     The  entire  spleen  was  removed. 
Recovery  followed  and  in  two  weeks  the 
wound   had    completelj'   healed.      0.    St. 
John  Moses  (Lancet,  Jan.  27,  1900). 
During  the  War  of  the  Eebellion  the 
proportion  of  deaths  was  93  per  cent. 
In  civil  life,  however,  the  weapons  used 
are,  as  a  rule,  less  powerful,  and  it  is 
probable  that  the  mortality,  especially 
since  antiseptic  surgerj'  has  been  gener- 
ally utilized,  is  much  smaller.    The  predi- 
lection of  this  organ  for  abscess  greatly 
darkens  the  prospects  of  recovery. 

Kidnetjs. — Complications  are  also  to  be 
feared  in  lesions  of  this  organ,  namely: 
peritonitis,  nephritis,  and  secondary  hsem- 
orrhage.  Again,  the  position  of  the  kid- 
ney makes  it  probable  that  other  organs 
are  also  injured  in  the  majority  of  cases. 
The  direction  from  which  the  bullet  or 
stab  came,  the  length  of  the  penetrating 
blade,  etc.,  are  important  factors  when 
the  nature  of  the  injury  is  to  be  deter- 
mined. 

Bladder.  —  Gunshot  wounds  of  the 
bladder  are  always  serious  as  far  as  com- 
plications are  concerned,  rectal,  vaginal, 
perineal,  and  scrotal  fistulse  being  very 
frequent. 

As  to  the  mortality  of  penetrating 
wounds  of  the  bladder,  it  is  not  so  great 
as  in  lesions  of  any  of  the  other  ab- 
dominal organs.  Stab  wounds  are  more 
frequently    mortal   than    imcomplicated 


28 


ABDOMEN.     PENETRATING  WOUNDS.     TREATMENT. 


bullet  wounds,  the  proportions  being  29 
per  cent,  in  the  former  and  17  per  cent, 
in  the  latter.  When,  however,  osseous 
lesions  are  also  present,  penetration  or 
fracture  of  the  pelvis,  etc.,  the  mortality 
reaches  29  per  cent. 

Case  in  which  a  crow-bar  entered  the 
right  thigh  in  front  and  emerged  below 
the  right  shoulder  posteriorly  about  an 
inch  and  a  half  below  the  angle  of  the 
right  scapula.  Notwithstanding  tox- 
Eemia,  hepatic  rupture,  and  the  presence 
of  septic  fluid  in  the  thorax,  patient  sur- 
vived the  injury  three  weeks.  A.  C. 
Miller  (Edinburgh  Med.  Jour.,  Oct.,  '99). 

Treatment.  —  The  preliminary  meas- 
ures indicated  in  the  treatment  of  com- 
plicated contusions  of  the  abdomen  are 
also  applicable  in  that  of  penetrating 
wounds  of  that  cavity.  Protrusion  of 
portions  of  the  intestines,  the  mesentery, 
and  the  omentum  through  the  external 
wound  is  an  early  complication  met  with 
in  many  cases  of  penetrating  wound.  If 
the  protruding  mass  be  intestinal  and  in 
good  condition  it  should  at  once  be  re- 
turned into  the  abdomen.  An  easy  way 
of  accomplishing  this  (recommended  by 
Levis)  is  to  raise  the  middle  of  the 
patient's'  body  by  means  of  a  pillow,  the 
hands,  etc.,  while  he  is  lying  on  his  back. 
The  anterior  portion  of  the  pelvis  is  thus 
separated  to  an  abnormal  degree  from 
the  anterior  portion  of  the  thorax,  and 
the  increased  room  in  the  abdominal 
cavity  thus  obtained  causes  the  intes- 
tines to  spread  out,  as  it  were,  and,  their 
weight  causing  traction  upon  the  pro- 
truding loop,  the  latter  quickly  slips  in. 
At  times  accumulation  of  gas  or  fsecal 
matter  checks  its  inward  progress;  the 
gas  can  easily  be  let  out  by  inserting  a 
clean  hypodermic  needle  into  the  pro- 
jecting bowel;  the  faecal  matter  can  also 
be  reduced  in  quantity  by  drawing  out 
an  additional  portion  of  the  gut — thus 
increasing    the    size    of    the   loop — and 


gently  pressing  small  portions  of  the 
contents  into  the  unprolapsed  bowel, 
thus  diminishing  the  tension  of  the  pro- 
truded mass.  It  is  sometimes  necessary 
to  enlarge  the  abdominal  wound.  If  the 
projecting  mass  be  greatly  inflamed  the 
latter  procedure  is  unavoidable.  If  it  be 
gangrenous  it  had  better  be  incised  and 
the  formation  of  a  faecal  fistula  per- 
mitted. 

An  omental  protrusion,  if  healthy,  can 
be  immediately  returned,  but  if  greatly 
inflamed  or  gangrenous  it  should  be 
transfixed  near  the  abdominal  wall  and 
tied  with  a  double  ligature;  then  excised. 
The  stump  is  then  secured  in  the  deeper 
portion  of  the  wound  with  ligatures  and 
adhesive  strips. 

Punctured  wounds  of  the  abdomen  are 
frequently  recovered  from  spontaneously, 
owing  to  the  absence  of  serious  visceral 
lesions.  The  same  statement  may  be 
made  as  regards  bullet  wounds,  but  with 
less  emphasis.  That  laparotomy  should 
be  performed  in  every  case  is  a  view  that 
wide-spread  clinical  testimony  does  not 
sustain;  but  that  a  wound  of  sufficient 
importance  to  cause  anxiety  be  enlarged 
down  to  the  peritoneum  to  allow  of  a 
careful  examination  and  adequate  pro- 
cedures, if  need  be,  and  that  laparotomy 
proper  should  be  reserved  for  lesions 
which,  from  the  nature  of  the  symptoms, 
tend  toward  a  fatal  issue,  is  in  keeping 
with  the  teachings  of  the  most  advanced, 
but  safe,  surgery. 

The  wound  of  entrance  should  be  en- 
larged, and,  if  the  missile  has  entered 
the  abdomen,  a  section  is  called  for. 
Operation  is  proper  soon  after  the  in- 
jury, before  the  peritoneal  membrane 
has  become  infected  or  much  blood  lost. 
Tiffany  (Amer.  Jour.  Med.  Sci.,  May, 
■96). 

Hypersesthesia  of  the  abdomen  is  an 
indication  for  operation.  An  increase  in 
the  respirations  to  twenty-eight  or  thirty 


ABDOMEN.     PENETKATIXG   WOUXUS..     XKEAT.ME.NT. 


29 


per  minute  is  an  absolute  indication  for 
operating.  Cold  extremities  are  also 
significant.  Le  Dentu  (Le  ProgrSs  Med., 
Oct.  27,  '97). 

When  surgical  measures  become  nec- 
essary, including  enlargement  of  the 
wound,  the  patient  should  be  placed  un- 
der an  anaasthetic.  The  rectum  should 
be  emptied  by  copious  injections  con- 
taining a  tablespoonful  of  glycerin  to 
the  pint.  A  subcutaneous  injection  of 
morphine  (V^  grain)  is  recommended  by 
many  surgeons.  If,  however,  there  is  a 
tendency  to  shock  without  much  pain, 
this  agent  had  better  be  withheld.  Rec- 
tal injections  of  whisky  and  warm  water, 
2  ounces  of  the  former  and  4  of  the 
latter,  is  useful  to  sustain  cardiac  action. 
It  may  be  repeated  in  an  hour  if  evi- 
dences of  impending  shock  are  still 
present. 

If,  after  a  careful  examination  of  the 
enlarged  wound,  it  is  found  that  the 
peritoneum  is  not  involved,  the  exposed 
tissues  are  carefully  cleansed  and  the 
wound  is  closed,  deep  sutures  being  used 
to  hold  the  tissues  in  accurate  apposi- 
tion. As  already  stated,  the  possibility 
of  ventral  hernia  should  be  borne  in 
mind:  the  patient  should  be  kept  in  bed 
for  some  time  and  a  bandage  be  worn 
until  all  local  weakness  has  disappeared. 

If,  after  a  stab  wound,  the  parietal 
peritoneum  alone  is  foimd  incised  or 
penetrated  and  there  is  no  evidence  that 
the  organs  behind  have  suffered  injury, 
the  tissiies  must  be  cleansed  with  great 
care  and  the  peritoneal  flaps  brought  to- 
gether, the  serous  surfaces  being  kept  in 
contact.  A  continuous  catgut  suture  is 
used  for  the  peritoneitm;  the  muscles 
and  skin  are  then  united  and  the  wound 
is  closed.  The  measures  already  out- 
lined to  prevent  ventral  hernia  are  also 
indicated  for  the  deeper  wound. 

When  laparotomy  becomes  necessary 


the  incision  should  be  made  in  a  spot 
affording  the  operator  the  greatest  op- 
portunity for  a  wide  field  of  action, 
and  should  be  sufficiently  long.  When 
performed  for  the  arrest  of  dangerous 
haemorrhage,  a  long  median  incision  will 
enable  the  surgeon  to  reach  any  organ 
with  ease:  an  important  factor,  for  the 
missile  or  blade  inflicting  the  injury  may 
have  traversed  harmlessly  between  sev- 
eral coils  of  intestine  and  have  caused  a 
rent  in  the  organ  most  remote  from  the 
point  of  entrance.  Again,  the  incision 
should  be  free,  so  as  to  make  it  possible 
to  easily  reach  all  parts  of  the  abdomen 
to  allow  of  a  thorough  removal  of  all 
extravasations  which  might  otherwise 
ultimately  cause  complications. 

Case  ending  fatally  through  the  fact 
that  a  too  limited  parietal  incision  had 
been  made.  A  longer  incision  would 
have  permitted  more  extensive  irrigation 
and  prevented  peritonitis,  which  devel- 
oped in  the  upper  portion  of  the  abdo- 
men. Dubujadoux  (Archives  de  Med.  et 
de  Pharm.  Militaires,  Aug.,  '95). 

In  most  cases  of  perforating  wound 
when  operation  is  decided  on  it  is  a  good 
plan  to  make  the  incision  through  the 
point  of  entrance,  and,  when  necessary, 
to  apply  silk-thread  retractors.  Charred 
tissue  must  be  excised,  and  the  part 
injured  secured  with  fingers  or  forceps 
and  drawn  out,  surrounded  by  gauze  or 
sponges,  and  dealt  with  by  suture  or  ex- 
cision as  the  case  requires.  When  flush- 
ing is  employed  for  the  removal  of 
foreign  matter  or  extravasated  fluid, 
some  clean  water  left  within  the  cavity 
often  has  a  very  beneficial  effect.  In 
hepatic  injury  often  the  chief  difficulty 
is  haemorrhage.  This,  however,  can  be 
stopped  by  pressure  with  or  A\ithout  per- 
chloride  of  iron  or  suture.  Wounds  of 
the  intestine  can  be  treated  expeditiously 
by  the  aid  of  some  sort  of  contrivance; 
but,  of  all  the  mechanical  instruments 
introduced.  Murphy's  button  is  the  best. 
J.  Ward  Cousins  (Brit.  Med.  Jour.,  Oct. 
21,  '99). 


30 


ABDOMEN.  PENETRATING  WOUNDS.  TREATMENT. 


One  of  the  important  elements  of  suc- 
cess in  the  treatment  of  gunshot  and 
stab  wounds  of  the  stomach  is  time. 
Unnecessary  time  lost  in  finding  and 
suturing  the  visceral  wounds  is  a  source 
of  immediate  danger  to  life  which  should 
be  eliminated  as  far  as  possible  by 
means    which    enable    the    surgeon    to 


fig.  1. — Suturing  of  posterior  wound  through 
anterior.  Purse-string  catgut  suture  in 
place.    (W.  Senn.) 

(British  Medical  Journal,  Nov.  8,  1902.) 

make  a  quick  and  correct  diagnosis,  and 
by  resorting  to  a  method  of  suturing 
which  closes  the  wound  safely  and  se- 
curely with  the  least  possible  delay, 
and  which  leaves  it  in  a  condition  most 
favorable  for  speedy  definite  healing. 
It  is  well  known  that  small  penetrating 
wounds  of  the  .stomach  often  heal  with- 
out operative  intervention.  By  contrac- 
tion and  relative  displacement  of  the 
different  muscular  layers  of  the  thick 
wall  of  the  stomach  the  tubular  wound 
is  contracted  and  obstructed  sufficiently 
to  prevent  leakage  until  the  canal  on 
the  peritoneal  side  becomes  hermetically 
sealed  by  firm  plastic  adhesions  which 
prevent  extravasation  during  the  time 
required  for  the  repair  of  the  visceral 
wound.  If  in  lai-ger  wounds  of  the 
stomach  the  same  degree  of  occlusion 
can  be  accomplished  by  the  simplest 
mechanical  means,  then  such  a  pro- 
cedure should  take  the  place  of  the  more 
time-consuming  methods  of  suturing 
now  in  general  use.  This  can  be  ac- 
complished with  the  purse-string  suture. 
In  gunshot  injuries  the  defect  in  the 
stomach-wall  is  circular  and  the  wound- 
margins  contused;  hence  the  deep  su- 
tures could  at  best  furnish  a  barrier 
to  the  escape  of  stomach-contents  only 


for  a  short  time,  as  their  hold  in  the 
necrosed  tissues  would  be  imperfect  and 
only  of  brief  duration.  In  short,  round 
wounds  the  circular  suture  is  the  one 
whicli  will  bring  and  hold  together  in 
permanent  uninterrupted  contact  the 
serous  surfaces  in  the  most  efficient 
manner.  In  the  treatment  of  gunshot 
wounds  of  the  stomach  the  principal 
object  of  suturing  should  be  to  close 
the  perforation  in  such  a  way  as  to 
guard  securely  against  extravasation, 
and  at  the  same  time  approximate  and 
hold  in  apposition  a  maximum  surface 
of  intact  healthy  peritoneum.  This  is 
accomplished  by  making  a  cone  of  the 
injured  part  of  the  stomach,  with  the 
apex  corresponding  with  the  wound  di- 
rected toward  the  lumen  of  the  organ. 
The  purse-string  suture,  applied  in  a 
manner  that  will  be  described  in  the  ex- 
perimental part  of  this  paper,  will  main- 
tain this  cone  until  the  healing  of  the 
visceral  wound  has  advanced  sufficiently 
to  render  further  mechanical  support 
superfluous.  The  cone  on  the  mucous 
side  of  the  stomach  acts  in  the  manner 
of  a  valve,  which  in  itself  is  an  effective 


Eig.  2. — Purse-string  silk  suture  in  place. 
(N.  Senn.) 

(British  .Medical  Journal,  Nov.  ,S,  1902.) 

barrier  against  the  escape  of  stomach- 
contents,  while  the  circular  suture  con- 
stitutes almost  an  absolute  safeguard 
against  leakage,  and  brings  in  contact 
the  serous  surfaces  in  the  interior  of 
the  cone.  For  wounds  of  the  posterior 
wall  of  the  stomach  the  author  recom- 
mends  a   purse-string   suture    of   heavy 


ABDOMEN.  PENETRATING  WOUNDS.  TREATMENT. 


31 


durable  eatgut  to  be  applied  through 
the  anterior  wound.  The  anterior 
wound  is  closed  with  a  purse-string  su- 
ture of  silk  of  medium  size  applied  to 
the  base  of  the  cone  on  the  serous  side. 
It  is  desirable  that  the  circular  suture 
should  cause  no  necrosis  of  the  included 
tissues.  By  using  an  absorbable  suture 
in  closing  the  posterior  wound  in  the 
interior   of   the   stomach  this   object   is 


Fig.  3. — Showing  result  of  purse-string  silk 
suture  closing  anterior  wound  in  stomach- 
wall.     (N.  Senn.) 

(British  MediOiil  Journal,  Nov.  8, 1302.) 

gained,  as  only  a  small  part  of  the 
thickness  of  the  stomach-wall  is  sub- 
jected to  pressure,  and  the  tension 
caused  by  the  ligature  is  gradually 
lessened  by  softening  of  its  material, 
and  is  entirely  removed  by  the  absorp- 
tion and  digestion  of  the  ligature  in 
less  than  three  weeks. 

The  wound  of  the  posterior  wall  of 
the  stomach  is  found  and  made  acces- 
sible by  inserting  through  the  anterior 
wound  a  grasping  forceps  with  which 
the  posterior  wall  is  seized  at  a  point 
where,  from  the  course  of  the  bullet, 
the  second  wound  is  supposed  to  be 
located.  Through  a  wound  large  enough 
to  admit  the  index  finger  the  greater 
part  of  the  posterior  wall  of  the  stom- 
ach can  be  made  accessible  to  sight  and 
touch,  and  the  perforation  can  be  lo- 
cated and  closed  with  the  purse-string 
suture  in  a  few  moments.  In  doubtful 
cases  inflation  of  the  stomach  should 
invariably  be  practiced  for  the  detec- 
tion of  a  second  and  possibly  a  third 
perforation. 

The  experiments  demonstrated  the 
safety  of  the  circular  suture  in  the 
treatment  of  gunshot  and  other  pene- 
trating wounds  of  the  stomach.  All 
•  of  the  animals  operated  upon  in  this 
manner  recovered,  and  the  repair  of  the 


injuries  as  shown  by  the  specimens  are 
ideal.  The  absence  of  adhesions  over 
the  posterior  wound  and  their  constant 
jiresenee  over  the  anterior  wound  indi- 
cate that  the  presence  of  the  silk  liga- 
ture and  the  needle  punctures  were  the 
causes  of  the  circumscribed  plastic 
peritonitis  which  produced  them.  In 
none  of  the  specimens  could  any  indica- 
tions be  found  of  necrosis  of  any  of 
the  inverted  tissues,  and  included  in 
part  by  the  circular  suture. 

In  the  course  of  three  weeks  the  con- 
tinuity of  the  mucosa  at  the  seat  of 
the  injury  was  completely  restored. 
The  result  of  these  experiments  has. 
convinced  the  author  that  the  circular 
suture  compares  favorably  with  the- 
methods  of  suturing  in  general  use,  and 
besides  has  the  great  advantages  over 
them  in  the  ease  of  its  application  and 
the  saving  of  much  valuable  time. 

Suturing  of  the  posterior  wound  by 
partial  eversion  of  the  stomach  through 
the  anterior  obviates  unnecessary  hand- 


Fig.  4. — Showing  in-igation  of  bursa  omentalis- 
through  the  opening  in  the  posterior  wall 
of  the  stomach.    (N.  Senn.) 

(liritiBh  Jledical  Journal,  Not.  8,  1902.) 

ling  of  the  organ  and  the  necessity  of 
interfering  with  the  vascular  supply  in- 
cident to  exposure  of  the  posterior 
wound,  as  is  done  by  the  methods  now 
generally  practiced.  If  extravasation 
into  the  retroga.strio  space  has  taken 
place,    flushing    through    the    posterior- 


32 


ABDOMEN.     PENETRATING  WOUNDS.    TREATMENT. 


wound  and  a  vertical  slit  in  the  gastro- 
colic ligament  and  gauze  drainage 
through  the  latter  are  invariably  in- 
dicated. N.  Senu  (Brit.  Med.  Jour., 
Nov.  8,  1902). 

The  stomach  and  the  transverse  colon 
are  best  brought  to  view  by  an  incision 
in  the  linea  alba.  In  the  case  of  the 
stomach  hernia  of  the  mucous  membrane 
will  facilitate  recognition  of  the  lesion. 
The  ascending  colon  requires  lateral  in- 
cision on  the  right  side,  and  the  descend- 
ing on  the  left.  These  also  should  be 
sufficiently  long  to  facilitate  the  search 
for  the  injury  or  injuries  that  may  be 
present  in  the  organ  itself  and  beyond. 

The  incision  may  be  such  as  to  inter- 
sect the  wound  of  entrance.  This  is  de- 
sirable at  all  times,  the  aim  being,  of 
course,  to  always  avoid  unnecessary  solu- 
tions of  continuity.  Sitch  an  incision 
can  fortunately  be  made  in  many  of  the 
cases  in  which  the  haemorrhage  is  not 
formidable. 

Hcemorrhage.  —  When  the  abdominal 
cavity  is  opened  and  the  haemorrhage, 
which  is  usually  more  venous  than  arte- 
rial, is  marked,  the  blood  rapidly  accu- 
mulates in  the  most  depressed  portion  of 
the  cavity  from  an  invisible  source.  To 
mop  out  the  blood  with  sponges  is  gen- 
erally recommended;  but  such  a  proced- 
ure does  not  cause  the  htemorrhage  to 
cease, — the  first  desideratum.  In  these 
formidable  cases  an  assistant  should  at 
once  introduce  his  hand  throiigh  the 
wound — hence  the  advisability  of  a  long 
incision — and  compress  the  abdominal 
aorta  below  the  diaphragm.  This  proced- 
ure immediately  checks  the  flow.  Care- 
fully cleansed  and  disinfected  sponges 
having  been  made  ready  in  the  mean- 
time, the  blood  present  is  quickly,  but 
not  roughly,  sponged  out.  When  this 
is  finished  the  source  of  haBmorrhage  is 
sought  after.    If  any  difficulty  is  experi- 


enced, the  digital  pressure  upon  the  aorta 
may,  for  an  instant,  be  decreased,  and  a 
sudden  gush  will  point  to  at  least  the 
direction  from  which  the  blood  comes. 
The  necessary  steps  are  then  taken  to 
arrest  the  flow,  and  the  abdominal  aortJi 
is  released  as  soon  as  possible, — not  sud- 
denly, but  by  a  gradual  reduction  of 
pressure. 

The  measures  to  be  adapted  in  arrest- 
ing hjemorrhage  vary  according  to  the 
organ  involved.  Gunshot  wounds  of  the 
liver  are  frequently  stellate,  and  rents, 
radiating  from  the  bullet-track  in  vari- 
ous directions,  greatly  increase  the  bleed- 
ing surface,  the  parenchyma  in  this  organ 
taking  part  to  a  great  degree  in  the 
emission  of  blood.  To  force  resilient 
sponges  into  thes€  tears  is  to  increase 
their  depth.  If  the  wound  be  not  very 
extensive,  it  may  be  sutured  with  catgut 
or  cauterized  with  the  actual  cautery. 
If  the  wound  is  extensive  it  had  better 
be  packed  with  long  strips  of  iodoform 
gauze,  one  end  of  which  is  brought  out 
of  the  external  wound. 

Five  cases  of  wounds  of  liver:  two  by 
fire-arms  and  three  by  a  cutting  instru- 
ment. Two  great  dangers  are  hsemoi-- 
rhage  and  infection.  Immediately  after 
accident,  if  there  is  indication  of  inter- 
nal hsemorrhage,  exploratory  laparotomy 
should  be  performed.  For  control  of 
haemorrhage  tampon  may  be  utilized  in 
grave  cases,  where  work  must  be  done 
quickly.  Suture  is  method  of  election. 
Statistics  show,  out  of  50  cases  of  oper- 
ative interference  in  hepatic  wounds, 
36  resulted  in  a  cure  and  14  ended 
fatally.  L.  Walton  (Araer.  Medico-Surg. 
Bull.,  Jan.  10,  '98). 

The  spleen  is  next  in  order  as  to  pro- 
fuseness  of  hsemorrhage.  The  same  pro- 
cedures may  be  adopted  as  for  the  liver, 
but  the  introduction  of  iodoform  strips 
is  to  be  preferred.  If  these  means  fail, 
splenectomy   is   the   only   measure   left. 


ABDOMEN.     PENETRATING  WOUNDS.     TREATMENT. 


33 


Sometimes  a  portion  of  the  organ  pro- 
jects through  the  wound;  removal  of  the 
protruding  portion  should  be  practiced 
after  passing  a  ligature  around  the  mass. 

Case  of  prolapse  of  spleen  through  a 
perforating  wound  of  the  abdomen  of 
three  weeks'  standing.  Spleen  at  first 
considered  to  be  the  liver,  though  on 
the  left  side,  on  account  of  the  size, 
shape,  and  color  of  the  organ.  Attempts 
to  reduce  it  failed.  It  slowly  contracted, 
becoming,  within  a  month,  less,  by  half, 
in  size,  and  contracted  very  firm  adhe- 
sions to  the  skin,  the  peritoneal  cavity, 
meanwhile,  being  completely  shut  off. 
As  there  had  been  a  compound  fracture 
of  the  tenth  rib,  with  subsequent  necro- 
sis of  the  broken  ends  of  the  bone,  a 
sinus  remained,  leading  from  the  pro- 
lapsed organ  to  the  bone;  and  here  the 
adhesions  were  very  vascular.  The 
pleura  had  escaped  uninjured.  Splenec- 
tomy. Uneventful  recovery.  E.  Harold 
Brown    (Brit.  Med.  Jour.,  Jan.   16,  '97). 

The  walls  of  the  stomach  and  intes- 
tines may  also  give  rise  to  marked  liEem- 
orrhage  notwithstanding  their  compara- 
tive thinness.  The  number  of  vessels 
coursing  through  them,  however,  is  very 
great.  In  these  cases  it  is  best  to  hem 
the  margins  of  the  wounds  with  tine  silk. 
The  bladder  may  be  treated  in  the  same 
way. 

The  mesentery  sometimes  bleeds  pro- 
fusely when  perforated.  The  mesenteric 
vessels  should  be  ligated  eti  masse  with 
fine  silk. 

Hemorrhage  of  the  kidney  is  arrested 
in  the  majority  of  cases  by  iodoform- 
gauze  package.  If  this  should  prove  in- 
effectual the  organ  must  be  exposed  and 
the  vessels  tied  if  possible.  If  not, 
nephrotomy  or  nephrectomy  should  be 
resorted  to.  The  latter  operation  does 
away  with  the  chances  of  complication 
attending  the  former,  while  the  kidney 
of  the  other  side  assumes  the  function  of 
both. 


Case  in  which  the  patient,  a  boy  of  8 
years,  was  shot  by  his  brother  with  a 
small  Elobert  pistol,  the  bullet  entering 
just  above  the  os  pubis  and  passing 
down  toward  the  right.  Considerable 
urine  extruded  from  the  wound,  and 
03dema  of  the  scrotum  and  penis  ap- 
peared. Incisions  allowed  the  escape  of 
considerable  urine  and  the  bullet  was 
also  extruded.  The  patient  rapidily  re- 
covered. B.  Bayerl  (Miinehener  med. 
Woeh.,  May  7,  1901). 

Perforation.  ■ —  To  detect  the  presence 
of  a  perforation  and  its  location,  Senn's 
hydrogen  test,  already  mentioned,  may 
be  employed. 

Senn's  method  of  hydrogen-gas  insuf- 
flation, however  admissible  in  recent 
eases,  should  be  used  with  great  caution 
after  the  lapse  of  a  few  hours.  The  dis- 
tension and  motion  of  the  intestines 
caused  by  the  insufflation  might  rupture 
inflammatory  adhesions,  burst  open  in- 
testinal wounds  that  had  nearly  healed, 
and  make  a  peritonitis  general  which 
had  become  circumscribed.  McGraw 
(Trans.  Amer.  Surg.  Assoc,  vol.  vii,  '89). 

The  fact  that  the  intestines  are,  at 
times,  perforated  in  twenty  spots  by  a 
bullet  suggests  the  considerable  degree 
of  care  that  should  be  given  to  this  part 
of  the  procedure,  which  is  carried  out 
in  the  following  way:  The  perforation 
nearest  the  rectum  having  been  detected, 
the  portion  of  intestine  perforated  is 
gently  brought  into  full  view.  An  as- 
sistant causes  the  gas  in  the  portion 
of  gut  below  the  laceration  to  escape 
through  the  latter  by  slight  pressure. 
This  being  done,  the  next  step  is  to 
ascertain  whether  there  is  another  perfo- 
ration above.  A  fresh,  perfectly  aseptic 
glass  tube  is  placed  at  the  end  of  the 
insufflating  tube  and  introduced  into  the 
wound  with  the  tip  directed  away  from 
the  rectum.  The  assistant  now  being 
directed  to  compress  the  intestine  below 
the  perforation,  a  small  amount  of  gas 


3-1 


ABDOMEN.  PENETRATING  WOUNDS.  TREATMENT. 


blown  above  the  latter  will  inflate  the 
upper  segment  if  there  is  no  opening,  or 
indicate  the  location  of  the  perforation 
if  there  is  one.  As  soon  as  the  latter  is 
detected,  the  tube  is  withdrawn,  the 
neighboring  intestine  on  each  side  of  the 
first  perforation  is  disinfected,  and  the 
opening  is  closed.  This  procedure  is 
renewed  until  all  perforations  have  been 
found  and  closed.  This  plan  renders  un- 
necessary the  renioval  of  the  intestines 
from  the  abdominal  cavity  during  any 
part  of  the  operation,  the  source  of  com- 
plications in  many  cases,  and  of  death  by 
aggravated  shock  in  others,  and  is  now 
recommended  by  the  majority  of  Amer- 
ican surgeons. 

There  is  great  ground  for  the  objec- 
tion to  Senn's  method,  made  by  many 
surgeons,  as  regards  its  use  for  purposes 
of  diagnosis  prior  to  laparotomy,  but,  in 
the  detection  of  perforations  after  the 
abdomen  has  been  opened,  it  is  of  value, 
and  may  be  used,  at  times,  to  great 
advantage. 

The  manner  of  closing  the  wound  is 
that  indicated  for  lacerations  following 
blows.  The  stomach  and  intestinal  per- 
forations being  treated  in  the  same  way, 
the  margins  of  the  wound  are  turned 
inward  and  the  serous  surfaces  are  imited 
by  a  continuoiTS,  fine-silk  Lembert  suture 
or  by  interrupted  sutures,  including  the 
serous  and  muscular  coats  and  the  sub- 
mucosa.  These  are  cut  short  and  left  in, 
being  eventually  discharged  per  anum. 

At  times  the  tissues  around  a  perfo- 
ration are  sufficiently  contused  to  render 
an  omental  graft  necessary. 

Entereetomy  is  sometimes  required, 
and  not  infrequently  exsections  of  the 
intestine  are  necessary.  In  that  ease  the 
intervening  portion,  if  it  is  not  too  long, 
had  better  be  resected,  thus  avoiding  a 
double  operation  in  the  continuity  of  the 
gut. 


Case  with  six  intestinal  perforations 
and  wound  in  bladder  4  centimetres 
long.  Resection  of  62  centimetres  of 
small  intestine.  Slight  cystitis;  recov- 
ery uneventful.  Eieder  (Le  Bull.  M6d., 
Jan.  3,  '95). 

After  the  active  measures  described 
have  been  carried  out  the  extravasation 
of  the  contents  of  the  stomach  or  intes- 
tines may  make  it  necessary  to  flush  the 
peritoneal  cavity.  Warm,  sterilized  water 
should  be  used,  but  care  should  be  taken 
not  to  handle  the  intestines  roughly.  By 
turning  the  patient  on  his  side  the  fluid 
is  poured  out.  The  abdominal  cavity  is 
then  dried  with  large  sponges  wrung  out 
of  warm,  sterilized  water.  Chilling  of 
the  viscera  shottld  be  carefully  avoided, 
and  the  parts  should  be  exposed  to  the 
air  as  short  a  time  as  possible. 

Case  of  stab  wound  illustrating  the 
value  of  salt  solution.  Within  the  abdo- 
men, where  only  salt  solution  was  used, 
no  inflammation  or  trouble  followed; 
A\hereas  at  the  abdominal  wound,  where 
bichloride,  etc.,  were  used,  suppuration 
took  place.  P.  R.  Bolton  (Med.  Record, 
July  31,  '97). 

Case  in  which  coeliotomy  for  gunshot 
wounds  disclosed  fourteen  perforations  of 
the  small  intestine.  Closed  with  con- 
tinuous and  Lembert  suture.  Abdom- 
inal cavity  flushed  with  saline  solution, 
drained  with  gauze;  recovery.  George 
Sherrill  (Med.  Record,  Oct.  7,  '99). 

Drainage  is  sometimes  necessary,  espe- 
cially for  wounds  of  the  solid  viscera, 
such  as  the  liver,  spleen,  kidneys,  etc., 
in  which  active  measures  were  not  re- 
sorted to  early. 

In  abdominal  surgery  the  weight  of 
evidence  stands  in  favor  of  dispensing 
with  drainage  whenever  it  is  possible. 
Method  of  closing  abdominal  wound 
layer  by  layer  has  greatest  number  of 
advocates,  and  materials  mostly  used 
for  sutures  are  catgut,  chromieized  cat- 
gut, silk-worm  gut,  and  silver  wire. 
Causes  of  post-operative  wound-infection 
fire  unnecessary  manifestations  of  wound, 


ABDOMEN.      WOUNDS  DUE  TO  illLITARY  ARMS. 


35 


rough  retraction  of  its  edges  and  pro- 
longed pressure  with  metal  retractors, 
imperfect  hsemostases,  strangulation  of 
large  bits  of  tissue  by  ligatures,  and  un- 
due tension  of  the  sutures.  A.  C.  Hef- 
fenger  (Med.  Record,  Dee.  17,  '98). 

Case  of  attempted  suicide  in  which  the 
intestine  was  wounded  with  a  pair  of 
scissors.  The  intestinal  wounds  were 
closed  with  silk,  mostly  by  interrupted 
sutures,  and  a  gauze  drain  was  carried 
out  of  the  median  end  of  the  wound 
and  the  walls  of  the  abdomen  closed. 
Recovery.  Deiters  (Miinch.  med.  Woch., 
Sept.  4,  1900). 

To  summarize:  we  will  say  that  imme- 
diate exploration  of  the  abdominal  cavity 
is  indicated  as  soon  as  it  is  suspected  to 
have  been  penetrated  or  in  any  way  in- 
jured by  a  traumatism.  The  injury  to 
its  contents  must  then  be  repaired  under 
strict  aseptic  precautions.  The  value  of 
salt-solution  flushing  is  emphasized  by 
the  results  of  practical  experience. 

ShoiUd  no  lesion  be  found,  the  mere 
exploration  should  result  in  no  serious 


After-treatment.  —  Food  should  be 
withheld  for  thirty-six  hours,  but  a  little 
water  and  brandy,  in  teaspoonful  doses, 
may  be  allowed,  especially  if  there  is 
any  degree  of  shock.  In  that  case  it 
is  advisable  also  to  use  stimulants  by 
the  rectum  or  subcutaneously.  Kutritive 
enemata  of  beef-tea  and  milk  are  neces- 
sary to  sustain  the  patient's  powers. 

In  three  cases  that  recovered  one  had 
16  wounds  of  the  small  intestine;  one, 
14,  and  another,  10,  and  it  would  seem 
almost  impossible  to  imagine  that  re- 
covery could  have  taken  place  in  these 
cases  without  operation.  The  after- 
treatment  is  regarded  as  all-important. 
During  the  first  twenty-four  hours  only 
cracked  ice  was  allowed  and  stimulants. 
On  the  second  day  the  patients  were  fed 
with  chicken-broth  at  intervals  of  two 
to  four  hours.  Rectal  feeding  with  pre- 
digested  foods  and  alcohol  was  practiced. 
A.  B.  Miles  (Annals  of  Surg.,  Dec,  '93). 


The  bowels  should  be  kept  freely 
movable.  Large  doses  of  Epsom  salts 
sometimes  serve  to  thwart  the  danger 
of  peritonitis,  without  compromising  the 
intestinal  wounds,  by  removing  all  nox- 
ious material  that  may  have  accumu- 
lated in  the  bowel. 

Liquid  food  may  be  permitted  by  the 
evening  of  the  second  day,  and  soft, 
easily  digested  food  after  a  week,  rectal 
alimentation  being  continued  until  then. 

The  sutures  can  be  removed  on  the 
ninth  day.  The  closure  of  the  external 
wound  must  be  complete  before  the  pa- 
tient can  be  allowed  to  leave  his  bed,  and 
the  danger  of  a  ventral  hernia  should  be 
counteracted  by  means  of  an  abdominal 
supporter. 

Hypodermic  injections  of  strychnine, 
^/go  to  V30  grain,  three  times  a  da)',  ac- 
cording to  indications,  will  prove  most 
effectual  in  maintaining  the  strength  of 
the  patient  and  toning  the  muscular  wall 
of  the  intestine. 

Wounds  Due  to  Military  Fire-arms. 

[See  supra,  Peneteating  "Wounds, 
for  details.] 

During  the  Franco-Prussian  War  Ger- 
man soldiers  were  frequently  found  suf- 
fering from  wounds  of  so  frightful  a 
nature  that  the  French  were  accused  of 
using  explosive  bullets  contrary  to  the 
International  Convention  to  that  effect. 
Wounded  limbs  showed  lesions  of  so  de- 
structive a  character  that  the  hole  made 
was  a  magma  of  muscle,  tendon,  bone, 
blood,  etc.  Dead  subjects  were  found 
with  their  heads  completely  shattered, 
the  brains  being  scattered  on  all  sides. 
The  good  faith  of  the  French  was  soon 
demonstrated,  however,  experiments  hav- 
ing shown  that  their  rifle,  the  Chasse- 
pot,  was  capable,  when  fired  at  close 
quarters,  of  creating  unusual  lesions  on 
account  of  the  initial  velocity  and  the 
greater  rotation  of  the  bullet.    This  was 


36 


ABDOMEN.     WOUNDS  DUE  TO  MILITARY  ARMS. 


attributed  mainly  to  the  reduced  diam- 
eter of  the  bore,  11  millimetres,  and  to 
the  increased  quantity  of  powder  used. 

In  1886  France  adopted  8  millimetres 
as  the  calibre  of  her  military  arm,  and 
the  other  nations  soon  followed  her  ex- 
ample. The  United  States  Government 
adopted  two  calibres,  one  of  7.62  mil- 
limetres for  the  army,  and  one  of  6  mil- 
limetres for  the  navy.  Contrary  to  all 
expectations,  the  effects  noted  in  recent 
wars,  the  war  between  Chili  and  Peru, 
in  which  a  7.6-millimetre  calibre  was 
used;  that  between  China  and  Japan, 
in  which  a  7.9-millimetre  was  used  on 
the  Japanese  side,  and  the  more  recent 
Chitral  expeditions  and  Abyssinian  cam- 
paigns, in  which  7.9-millim-etre  and  6.5- 
millimetre  arms,  respectively,  were  em- 
ployed, were  less  destructive  than  the 
larger  calibres,  while  the  wounds  caused 
by  them  healed  with  greater  rapidity 
than  those  following  lesion  due  to  the 
action  of  larger  balls.  During  the  Chil- 
ian War  there  were  instances  where  men 
completely  perforated  through  the  chest 
would  suffer  from  slight  shock,  a  slight 
hasmoptysis,  and  soon  be  out. 

This  radical  difference  between  the 
•destructive  power  of  large  and  small  cali- 
bres, or,  rather,  between  the  destructive 
■effects  of  an  arm  such  as  the  Chassepot 
(11  millimetres)  and  the  modern  rifle 
(6  to  8  millimetres),  is  mainly  attributed 
to  the  fact  that  lead  was  formerly  em- 
ployed in  the  manufacture  of  bullets; 
whereas,  at  present,  in  order  to  avoid 
destruction  of  the  bullet  during  its  prog- 
ress through  the  barrel,  resulting  from 
the  great  increase  of  the  powder-charge, 
and  with  the  view  of  reducing  the  weight 
carried  by  the  soldier,  owing  to  the  in- 
troduction of  repeating  arms,  the  bullet 
itself  is  either  made  of  some  hard  metal, 
or  it  is  covered  with  some  such  substance 
as  nickel,  steel,  German  silver,  etc. 


These  physical  features,  added  to  the 
smaller  diameter  of  the  projectile,  the 
much  greater  velocity  with  which  it 
travels,  its  more  or  less  pointed  tip, 
causes  it  to  penetrate  soft  tissues  as 
would  a  long,  thin  blade,  separating- 
rather  than  destroying  them.  There- 
fore perforations  in  a  muscle  are  clean- 
cut;  at  times  their  walls  are  even  col- 
lapsed; as  a  rule,  the  channel  is  about 
the  size  of  the  bullet;  large  blood-vessels 
are  severed  and  bleed  until  the  heart 
ceases  to  beat,  etc. 

Experiments  on  dead  bodies  seemed  to 
show  that  very  different  effects  were  to 
be  expected  as  soon  as  any  resistance  was 
offered  to  the  passage  of  the  bullet. 
When  the  skull  was  struck  even  at  long 
range  (1100  metres,  Kocher),  for  in- 
stance, the  brain  was  completely  disor- 
ganized and  the  skull  was  fractured  in 
all  directions,  while  at  short  range  ex- 
plosion of  the  head  might  be  said  to 
have  taken  place.  But  experiments  on 
dead  bodies  are  now  known  to  furnish 
but  little  accurate  information  as  regards 
the  effect  of  projectiles,  the  living  tissues 
being  affected  differently.  At  short 
range  destructive  effects  on  soft  and 
hard  tissues  are  produced,  but  these  do 
not  vary  from  those  by  older  weapons  at 
equal  distances. 

Accepting  only  as  evidence  that  fur- 
nished by  the  use  of  small-calibre  bullets 
on  the  living,  it  may  be  said  that  the 
arms  now  furnished  to  armies  do  not 
give  rise  to  injuries  such  as  those  met 
with  in  civil  life,  when  weapons  of  vari- 
ous kinds,  imparting  to  bullets  a  much 
smaller  velocity,  are  used. 

It  is  evident,  judging  by  the  practical 
evidence  at  present  at  our  disposal,  that 
military  gunshot  wounds  cannot  be  con- 
sidered absolutely  as  belonging  to  the 
category  reviewed  in  this  article.  But  it 
is  only  a  question  of  degree  as  to  the 


ABDOMEN.     WOUNDS  DUE  TO  MILITARY  ARMS. 


37 


injuries  inflicted,  and  the  military  sur- 
geon, by  exercising  his  usual  powers  of 
discernment,  will  find  a  larger  number 
of  curable  cases,  whenever  the  severe 
haemorrhages  frequently  attending  the 
use  of  these  new  weapons  will  not  have 
caused  death  soon  after  the  receipt  of 
the  injury. 

Wounds  of  the  thorax  and  abdomen 
divide  themselves  into  penetrating  and 
perforating.  It  must  not  be  forgotten 
that  a  slight  haemoptysis  may  accom- 
pany the  first  type,  from  the  mere  im- 
pact of  the  blow.  In  all  wounds  the 
probe  is  always  eontra-indieated.  As 
to  the  prognosis  of  chest  wounds,  sta- 
tistics are  very  pessimistic,  for,  unless 
the  cases  die  within  the  first  two  or 
three  hours  or  are  killed  by  meddlesome 
surgery,  they  recover  in  a  vast  majoritj' 
of  cases.  It  is  certain  that  here  a 
masterly  inactivity  should  characterize 
the  operator.  In  dealing  with  lodged 
balls  the  author  cannot  do  better  than 
quote  Abernethy,  who,  in  speaking  to 
his  students,  said  that  when  Sir  Ralph 
Abercrombie,  who  had  received  a  bullet 
in  the  thigh,  was  placed  under  the  sur- 
geon's care,  "they  groped  and  they 
groped  and  they  groped,  and  Sir  Ralph 
died."  It  must  be  remembered  that  per- 
forating wounds  of  the  abdomen  do  not 
in  many  cases  enter  through  the  ab- 
dominal wall.  Many  have  entered  via 
the  pelvis  or  the  chest.  In  wounds 
above  the  umbilicus,  probably,  there  are 
3  per  cent.  Avhich  penetrate  without  per- 
forating. The  direction  of  the  bullet 
has  importance,  the  antero-posterior 
being  better  than  the  oblique,  and  these, 
in  turn,  being  more  favorable  than  the 
flank-to-flank  type.  Prognosis  is  based 
properly  upon  the  statistics  of  many 
eases.  These  in  general  show  that  un- 
operated  cases  give  a  55-per-cent.  mor- 
tality. In  patients  operated  upon  dur- 
ing the  first  4  hours,  there  is  but  1.5 
per  cent. ;  in  4  to  8  hours,  44  per  cent. ; 
in  9  to  12  hours,  63  per  cent. ;  after 
12  hours,  70  per  cent.  The  speaker 
emphasizes  the  importance  of  early 
diagnosis.  Faecal  extravasation  usually 
does  not  occur  until  after  the  fourth 
hour.     This   is    due    partly    to    the    in- 


testinal paresis  resulting  from  the  im- 
pact. The  treatment  is  to  cover  the 
wound  and  not  handle  it  too  much. 
Infusion  of  very  free  type  and  equally 
generous  drainage,  particularly  in  civil 
practice,  are  both  indicated.  Injuries 
of  the  posterior  cavity  call  for  posterior 
drainage.  Seeking  the  ball  is  contra- 
indicated;  unless,  indeed,  it  comes  into 
view  without  efl'ort,  it  should  be  let 
alone.     (William  L.  Rodman.) 

Many  men  are  led  astray  by  the  old 
and  erroneous  teaching  that  the  circuit- 
ous route  in  the  abdomen  is  an  utter 
impossibility.  It  may  chance  that  a 
spent  bullet  striking  the  skull  may  be 
deflected  by  the  bone,  but  no  bullet  can 
be  turned  aside  by  the  soft  viscera. 
Another  point  is  that  the  shape  of  the 
abdomen  is  constantly  changing.  It  is 
by  no  means  difficult  to  place  an  athlete 
in  such  a  position  of  strain  that  the 
anterior  abdominal  wall  is  in  contact 
with  the  backbone.  This,  no  doubt, 
explains  the  anomalous  conditions  where 
bullets  have  traversed  the  abdomen 
without  injuring  the  viscera.  (Mc- 
Graw.) 

Army  surgeons  are  averse  to  early 
operations  on  the  field.  The  fact  that 
officers  who  had  lain  in  the  open  for 
twenty-four  hours  with  no  care  save  a 
protective  dressing,  with  absolutely  no 
food  or  drink,  have  recovered,  is  in- 
structive ;  it  may  very  likely  be  that 
such  absence  of  eating  or  drinking  is  a 
desideratum.     (Grant.) 

The  importance  of  venesection  in  in- 
cipient pneumonia  following  bullet 
wounds  should  not  be  overlooked. 
Shock  is  entirely  distinct  from  bfemor- 
rhage.     (Roberts.) 

All-important  treatment  in  the  case 
of  chest  wounds  is  absolute  costal  im- 
mobilization. The  manner  of  accom- 
plishing this  is  to  put  on  a  cast  of 
either  plaster  of  Paris  or  rubber  plaster, 
extending  from  the  umbilicus  to  and 
over  the  shoulders.     (Ochsner.) 

The  prognosis  depends  very  materially 
on  whether  the  viscera  are  full  or 
empty.  If  empty,  the  same  forces  whicli 
when  full  extrude  food  close  the  wound. 
The  value  of  aseptic  food  has  been  al- 
together overestimated,  for  the  alimen- 
tary canal  contains  about  every  known 


38 


ABDOMEN. 


pus-producing  organism.  It  is  tlie  in- 
jury to  the  mucous  membrane  which 
kills  the  patient.     (Laplace.) 

In  controlling  the  haemorrhage  from 
chest  \Younds  a  most  valuable  method 
was  that  of  cording  three  extremities 
for  fifteen  minutes,  then  passing  on  to 
the  fourth,  alternating  in  this  way  for 
several  hours.  It  serves  the  same  pur- 
pose as  venesection,  but  preserves  the 
blood.  The  author  has  heard  from  a 
great  many  of  his  old  students,  who 
have  been  operating  in  the  Philippines 
and  Cuba,  and  gave  their  reports  to  him 
in  detail.  They  agreed  thai  on  the  bat- 
tlefield operations  cannot  be  done  be- 
cause of  the  absence  of  two  essentials: 
fire  and  water.  The  value  of  morphine, 
pushed  to  its  limit,  which  constitutes 
a  so-called  opium  splint  and  which 
makes  the  patient  comfortable,  is  prob- 
ably a  very  important  factor  in  saving 
lives.  (Dawbarn.)  Proc.  Amer.  Med. 
Assoc.  (N.  Y.  Med.  Jour.,  June  14,  1902). 
Our  recent  campaign  has  but  verified 
the  teachings  just  outlined. 

Eknest  Laplace, 

Philadelphia. 

ABDOMINAI      ANEURISM.        See 

Aneukisji. 

ABORTION. 

Definition. — Abortion  is  a  term  used 
to  denote  the  expulsion  of  the  product 
of  conception,  aliye  or  dead,  during  the 
first  six  months  of  pregnancy;  or,  more 
exactly,  the  expulsion  of  a  product  of 
pregnancy  which  has  not  yet  attained 
the  period  of  viability,  thus  including 
cases  where  the  foetus  may  perish  dur- 
ing the  sixth  month  of  pregnancy  and 
be  delivered  a  month  or  so  later. 

A  number  of  authorities,  especially 
American  and  English,  only  apply  the 
term  "abortion"  to  expulsion  of  the 
ovum  during  the  first  three  months, 
while  "immature  delivery"  and  "miscar- 
riage" are  applied  to  expulsion  of  the 
product  of  conception  from  the  end  of 


the  third  month  to  that  of  the  seventh, 
— i.e.,  from  the  formation  of  the  pla- 
centa to  the  time  the  child  becomes 
viable.  When  the  expulsion  takes  place 
between  the  period  of  viability  and  the 
normal  term  of  pregnancy,  it  is  called 
"premature  delivery." 

Frequency. — It  is  difficult  to  ascer- 
tain the  frequency  of  abortion  (1)  be- 
cause during  the  first  two  months  of 
pregnancy  it  often  occurs  without  being 
detected;  (2)  because,  when  known  and 
even  when  occurring  at  a  late  date,  it  is 
frequently  allowed  to  go  without  treat- 
ment. 

The  statistics  obtained  in  maternities 
give  a  proportion  of  one  abortion  to 
three  normal  pregnancies;  but  such  a 
proportion  cannot  be  accepted  as  a  rule, 
lying-in  hospitals  receiving  only  women 
in  an  advanced  state  of  pregnancy.  It 
is  generally  admitted  that  spontaneous 
abortion  occurs  most  frequently  during 
the  first  three  months  of  pregnancy. 

Viability.  —  Until  recently  the  f CBtus 
was  clinically  looked  upon  as  viable  only 
after  the  seventh  month;  but  more  care- 
ful treatment — above  all,  the  use  of  the 
incubator  and  of  artificial  feeding  by 
means  of  the  stomach-tube — has  caused 
children  born  during  the  sixth  month  to 
be  looked  upon,  clinically,  as  well  as 
legally,  as  viable. 

A  very  young  fcetus  may  breathe  after 
delivery.  This  occurred  in  three  cases 
in  the  fifteenth,  fifteenth,  and  nineteenth 
Aveeks  respectively.  In  the  first  of  these 
there  were  sis  respiratory  movements  be- 
fore and  five  after  severing  the  cord,  the 
foetus  living  one  hour.  In  the  second 
case  the  foetus  lived  an  hour  and  a  half 
and  breathed  five  times.  The  third  foetus 
lived  but  half  an  hour  and  breathed 
eight  times.  The  autopsy  showed  air  in 
the  stomach,  but  the  lungs  were  empty. 
Glockner   (Cent.  f.  Gyn.,  No.  1,  '90). 

In  performing  an  autopsy  upon  a 
M'oman    who    is    supposed    to    have    at- 


ABORTION.    SYMPTOMS. 


39 


tempted  abortion  search  should  be  made 
for  the  embryo  or  pieces  of  it,  or  for 
the  placenta.  If  the  uterus  is  empty, 
the  thickness  of  its  walls  must  be  meas- 
ured, and  the  insertion  of  the  placenta 
sought,  as  this  can  be  recognized  up  to 
the  tenth  day  after  the  expulsion  of 
the  embryo.  This  is  possible  even  later, 
if  the  uterus  is  kept  in  90  per  cent, 
alcohol.  The  examination  of  the  ovaries 
is  of  only  relative  importance,  as  no 
positive  signs  exist  there.  Stains  of 
meconium,  if  found,  will  prove  the  abor- 
tion. If  an  instrument  has  been  used 
to  cause  abortion,  traces  of  the  damage 
done  by  it  will  be  seen.  This  is  espe- 
cially true  when  the  uterus  has  been 
perforated.  Brouardel  (Jour,  des  Pra- 
ticiens,  .Jan.  12,  1901). 

Symptoms. — Abortion  is  divided  as  to 
its  symptomatology  by  the  majority  of 
obstetricians  into  four  classes: — 

1.  Abortion  occurring  during  the  first 
month. 

2.  Abortion  occurring  during  the  sec- 
ond month. 

3.  Abortion  occurring  between  '  the 
beginning  of  the  third  month  and  the 
end  of  the  fourth  month. 

•i.  Abortion  occurring  during  the  fifth 
and  sixth  months. 

After  the  third  montli  the  abortion 
presents  very  distinct  clinical  characters. 

Abortion  in  general  is  ustially  pre- 
ceded by  dysmenorrhceal  pains,  extend- 
ing as  far  as  the  loins,  and  a  sensation 
of  bearing  down  in  the  pelvis,  or  con- 
tractions of  the  uterus  with  or  without 
haemorrhage. 

When  the  death  of  the  foetus  precedes 
the  abortion,  the  uterus  ceases  to  in- 
crease in  size,  and  all  reflex  symptoms 
caused  by  pregnancy  disappear. 

Abortion  During  the  First  Month. — 
This  usually  gives  rise  to  symptoms 
simulating  those  of  retarded  menstrua- 
tion. Slight  pains  in  the  back  in  the 
region  of  the  uterus  are  complained  of; 
the  symptoms,  in  this  particular,  resem- 


ble those  of  normal  labor,  but  are  very 
much  less  marked.  Blood,  blood-clots, 
and  flakes  of  the  mucous  membrane  of 
the  uterus  are  gradually  expelled  during 
several  days.  The  ovum  is  expelled  en- 
tire, but  it  is  so  small  that  it  is  rarely 
discovered. 

Abortion  During  the  Second  Month. — 
Inasmuch  as  the  uterus  has  decidedly 
increased  in  size  as  compared  to  the  flrst 
month,  the  contractions  and  pains  are 
proportionately  stronger.  The  embryo 
is  usually  expelled  inclosed  in  the  un- 
broken membranes.  Sometimes,  how- 
ever, the  latter  are  ruptured. 

The  embryo  and  membranes  may  be 
detached  from  the  uterus  in  two  ways: 

(a)  By  hemorrhage  between  the  mem- 
branes and  the  uterus,  followed  by  uter- 
ine contraction. 

(6)  By  contraction  of  the  uterus,  fol- 
lowed by  hsemorrhage.  In  the  latter  case 
the  abortion  is  more  prolonged,  the  mem- 
branes being  detached  biit  slowly  from 
the  uterus. 

If  the  embryo  be  still  living,  the  abor- 
tion lasts  longer,  and  the  haemorrhage 
is  greater.  If  the  embryo  be  dead,  the 
whole  is  usually  expelled  like  a  foreign 
body,  and  without  rupture  of  the  mem- 
branes. 

Examination  of  the  uterus  will  show 
that  it  is  increased  in  volume,  and  situ- 
ated lower  down  in  the  pelvis  than  nor- 
mally. The  cervix  is  dilated,  softened, 
and  filled  with  blood-clots.  The  dilata- 
tion is  more  marked  in  multiparse  than 
in  primiparffi. 

The  cervix,  though  dilated,  does  not 
become  effaced;  and  the  embryo  con- 
tained in  the  unruptured  membranes 
may  pass  through  the  cervix  and  be  ex- 
pelled. If  the  membranes  are  ruptured, 
however,  the  embryo  passes  by  itself,  the 
very  thin  umbilical  cord  breaks,  and  the 
cervix  closes.     The  membranes  are,  in 


40 


ABORTION.     SYMPTOMS. 


this  latter  case,  expelled  later  on.  The 
membranes  are  ruptured  about  once  in 
every  two  cases. 

Abortion  from  the  Beginning  of  the 
Third  to  the  End  of  the  Fourth  Month. — • 
This  occurs  nearly  always  in  two  stages, 
the  first  consisting  in  the  expulsion  of 
the  foetus,  and  the  second  in  the  expul- 
sion of  the  membranes  and  placenta. 

The  cervix  in  this  form  of  abortion 
tends  to  diminish  in  length.  The  uter- 
ine contractions  act  more  powerfully 
than  in  the  previous  forms  of  abortion. 
Under  their  influence  the  membranes  are 
ruptured  and  the  fretus  is  expelled. 

The  placenta  may  still  be  adherent; 
the  cervix  then  closes  again,  and  the 
placenta  and  membranes  are  expelled 
later  on.  Hgemorrhage  is  likely  to  ac- 
company the  delivery  of  the  placenta 
and  membranes,  especially  when  the 
former  is  only  partly  detached.  Under 
these  circumstances  each  uterine  con- 
traction is  accompanied  by  htemorrhage. 
The  placenta  may  be  already  detached 
when  the  foetus  is  expelled;  in  such  a 
case  it  is  likely  to  be  expelled  imme- 
diately after  the  latter,  before  the  cervix 
closes,  but  part  of  the  decidua  may  re- 
main in  the  uterus  after  delivery  of  the 
placenta.  This  occurs  most  frequently 
when  the  foetus  is  dead. 

Statistics  show  that  retention  of  the 
placenta  occurs  most  frequently  during 
this  period. 

At  three  months  the  placental  form  is 
well  established,  and  the  uterine  contents 
behave  much  as  they  do  at  full  term, 
with  these  differences:  the  placenta  is 
less  firmly  put  together  and  is  more 
firmly  united  to  the  uterus.  There  is 
danger,  therefore,  of  masses  of  placenta 
being  retained,  even  though  much  may 
be  expelled.  Ayers  (N.  Y.  Med.  Record, 
Sept.  28,  '95). 

Abortion  During  the  Fifth  and  Sixth 
Months. — The  foetus  and  placenta  are  al- 


most always  expelled  separately.  Uterine 
contraction  is  more  marked;  the  cervix 
tends  to  become  more  efEaced  and  to 
dilate. 

Delivery  of  the  placenta  usually  fol- 
lows delivery  of  the  foetus  rapidly,  and 
the  tendency  to  hsemorrhage  is  less 
marked  than  in  the  previous  forms  of 
abortion. 

Of  501  cases  of  abortion  analyzed  by 
Varnier  and  Brion,  the  foetus,  or  em- 
bryo, and  the  placenta  were  expelled 
separately  in  453,  and  together  in  48 
cases.  When  the  delivery  occurred  in 
two  stages,  the  time  found  to  elapse 
between  the  expulsion  of  the  fcetus  and 
that  of  the  placenta  was  as  follows:  120 
eases,  within  15  minutes;  81  cases,  from 
15  to  30  minutes;  78  cases,  from  30  to 
60  minutes;   83  cases,  from  1  to  4  hours. 

In  275  cases  treated  in  the  last  two 
years  of  those  eases  terminating  natu- 
rally expulsion  of  the  whole  ovum  oc- 
curred in  hospital  in  145  cases.  The 
remaining  39  were  admitted  with  the 
placenta  partially  or  entirely  retained. 
Complete  expulsion  occurred  after  a 
period  varying  from  a  few  hours  to  three 
days  as  a  maximum.  During  this  time 
rigorous  antiseptic  precautions  were  ob- 
served (douches,  etc.).  All  these  cases 
terminated  favorably  with  two  excep- 
tions: one  patient  was  septic  on  ad- 
mission, and  died  of  septicaemia;  the 
other  case  died  of  pulmonary  tubercu- 
losis. Maygrier  (L'Obstetrique,  July, 
'97). 

Whenever  the  placenta  and  membranes 
are  not  expelled  within  four  hours  after 
the  expulsion  of  the  fcetus,  or  embryo, 
there  is  retention  of  the  membranes  and 
placenta. 

Abortion  may  take  place  suddenly,  or 
resemble,  in  that  particular,  the  irregular 
periodicity  of  normal  labor,  with  more  or 
less  hsemorrhage.  It  may,  indeed,  last 
several  days,  owing  to  weakness  of  the 
uterine  contractions  or  adhesions  to  the 


Development  of  the  ovum  (Caseaux,  Hunter, Erdl,  &c  ) 

Fiqures  3  and  b   The  ovum  during  the  second  and  fourth  week    Fiqure  c  Seclion  of  the  uterus  '  reduced  I  showinq  thei 
thickened  mucous  membrane  which  is  fofurnish  the  decidua  vera.  FiqurEsdand,dTheo«um  attheendofthesixlh  week 


ABORTION.     PATHOLOGY.     COMPLICATIONS. 


41 


uterus  or  retention  in  the  cervix  of 
the  masses  to  be  expelled.  (Kokitansky, 
Schlilein.) 

Sudden  or  rapid  abortion  is  frequent 
during  the  first  two  months;  when  the 
expulsion  takes  place  after  the  third 
month  it  generally  presents  the  charac- 
ters of  normal  delivery. 

Pathology.  —  Abortion  comprises  a 
period  of  uterine  dilatation,  the  expul- 
sion of  the  ovum,  and  involution  of  the 
uterus;  when  delay  occurs  in  any  one 
of  these  three  stages  the  abortion  is 
protracted.  The  most  frequent  cause 
is  failure  of  the  os  and  cervix  to  dilate, 
resulting  from  a  rigid  condition  of  the 
tissues  following  laceration  or  previous 
inflammation.  The  internal  os  may  be 
closed  and  the  external  os  and  cervix 
dilated,  or  the  external  os  may  be  closed 
while  the  internal  is  dilated.  The  mus- 
cular wall  of  the  lower  portion  of  the 
ut«rus  is  thinned  in  abortion,  so  as  to 
give  a  lower  segment,  which  is  as  well 
marked  in  the  aborting  uteriTS  as  in  the 
uterus  in  labor  at  full  term.  The  peri- 
toneum over  this  part  of  the  uterus  be- 
comes loosened,  as  the  result  of  the  ex- 
pansion of  the  museiilar  wall;  and  the 
deeidua  over  the  same  area  is  also  sepa- 
rated from  the  same  cause.  (Berry 
Hart.) 

Complications. 

Eetention  of  the  Secundines.  — 
This  is  the  most  frequent  complication 
of  abortion,  spontaneous  or  criminal, 
and  may  present  either  of  the  following 
characters:  The  placenta  is  non-adher- 
ent, but  remains  within  the  uterine 
cavity  until  finally  expelled,  either  en- 
tire, or  in  pieces.  As  infection  easily 
occurs  in  such  a  case,  great  attention 
should  be  paid  to  the  temperature.  The 
placenta  remains  completely  adherent. 
When  this  is  the  case  the  placenta  is 
expelled  only  some  days  later,  as  late 


even  as  thirty  days  after  delivery  of  the 

fcetus. 

[According  to  some  autliors,  the  pla- 
centa may  be  absorbed  and  no  expul- 
sion occur.  This  opinion  cannot  any 
longer  be  admitted.  When  the  placenta 
remains  for  years  in  the  uterine  cavity 
without  producing  alarming  symptoms 
it  is  likely  to  become  transformed  into  a 
mole.    A.  LuTAUD.] 

The  placenta  is  partly  adherent  and 
partly  non-adherent.  This  is  the  most 
dangerous  condition,  as  it  is  the  most 
liable  to  be  accompanied  by  hasmorrhage 
or  septicsemia.  Great  care  should  be 
taken  in  such  a  case  not  to  pull  on  the 
placenta,  lest  more  haemorrhage  be  pro- 
duced by  further  detachment. 

An  entire  placenta  in  the  uterus  is 
not  dangerous,  but  fragments  rapidly 
give  rise  to  grave  sj'mptoms.  Bureau 
(Jour,  de  Med.,  Apr.  3,  '92). 

Tetanus  after  abortion.  The  latter 
occurred  during  the  third  month.  The 
uterus  was  properly  cleared,  but  on  the 
ninth  day  the  temperature  rose,  then 
fell  after  an  injection  of  collargolin. 
Trismus  was  observed  on  the  next  day, 
followed  by  tetanus,  which  grew  worse 
till  the  fifteenth  day.  Numerous  in- 
jections of  Behring's  tetanus  antitoxin 
were  administered,  and  recovery  fol- 
lowed. Osterloh  (Monats.  f.  Geb.  u. 
Gyniik.,  Aug.,  1902). 

HEMORRHAGE. — Haemorrhage  may  oc- 
cur during  the  detachment  of  the  ovum 
itself,  during  the  detachment  of  the  pla- 
centa immediately  after  delivery  of  the 
foetus,  or  during  detachment  of  the  pla- 
centa, the  latter  occurring  several  days 
after  delivery  of  the  fcetus. 

The  blood  may  be  normal  and  be  at 
once  expelled  from  the  genital  organs; 
or  it  may  form  a  half-coagulated  mass 
within  the  vagina.  Masses  of  fibrin  in 
the  blood  should  be  diagnosed  from  the 
ovum  itself,  for  which  they  may  be  mis- 
taken. 

The  symptoms  are  those  of  all  forms 


42 


ABORTION.     COMPLICATIONS.     ETIOLOGY. 


of  hsemorrhage.  When  profuse  there  is 
a  weak  pulse,  pallor,  disturbances  of 
hearing  and  sight,  and  vertigo. 

The  danger  from  the  hsmorrhage  is 
not  so  great  as  the  general  symptoms 
would  often  indicate;  still,  any  serious 
loss  might  diminish  resistance  to  infec- 
tion. 

Cases    of    haemorrhage    before    miscar- 
riage, indicating  the  advisability  of  rap- 
idly  bringing   the   abortion    to    an    end 
when  the  loss  of  blood  is  serious.    Martin 
(N.    Y.    Med,    Jour.,   Feb.,   '92);     Blood 
(Chicago  Med.  Times,  Aug.,  '92) ;    Hirst 
(Amer.  Gyn.  Jour.,  Feb.,  '92). 
Inversion  of  the  Uterus. — Inver- 
sion of  the  uterus  is  occasionally  ob- 
served as  a  complication.     The  uterine 
wall  should  be  handled  with  care  when 
efforts  at  reduction  are  made,  pressure 
with  finger-tips  being  avoided. 

But  1  case  of  inversion  of  uterus  met 
with  in  190,000  labors  at  Rotunda  Hos- 
pital; 250,000  births  were  recorded  in 
Vienna  without  a  ease.  Case  of  patient 
who  had  three  living  children,  but  dur- 
ing fifteen  months  preceding  entrance 
into  hospital  she  had  miscarried  four 
times  between  third  and  fourth  month. 
On  fifth  day  following  last  miscarriage 
she  flowed  freely,  with  sudden  pain  in 
abdomen,  attended  with  collapse.  She 
remained  in  bed  six  weeks.  Two  days 
after  getting  vip  she  felt  that  something 
came  down  and  endeavored  to  keep  it 
back  with  a  cloth.  Examination  detected 
inversion  of  uterus.  The  mucous  mem- 
brane of  uterus  showed  no  tendency  to 
become  dry  and  skin-like.  Several  days 
later  uterus  menstruated,  which  lasted 
four  days.  Under  ether,  reduction  was 
accomplished  only  by  making  free  in- 
cisions into  the  cervix  and  longitudinal 
incisions  over  uterine  mucous  membrane 
at  region  of  internal  os,  in  addition  to 
continued  pressure  kept  up  on  neck  of 
swelling  and  over  its  surface.  Patient 
subsequently  became  pregnant  and  was 
delivered  at  term  without  trouble. 
A.  W.  W.  Lea  (Med.  Chronicle,  vol.  viii. 
No.  3,  p.  177,  '98). 
Septicemia. — Septicsemia  frequently 


accompanies  excessive  haemorrhage.  It 
may  be  revealed  by  foetidity  of  the 
lochia.  The  latter  symptom  is  not  in- 
variably present,  however,  as  no  odor 
may  be  noticed,  notwithstanding  active 
septicaemia.  Chill  and  high  temperature 
may  be  considered  as  the  positive  signs 
of  infection. 

Case  in  which  abortion   was  followed 
by  septic   endometritis,   salpingitis,   gen- 
eral peritonitis,  and  an  abscess  of  each 
ovary.     Dorsett    (Weekly  Med.   Review, 
Feb.  14,  '91). 
Tetanus,  etc.  —  Tetanus  and  other 
nervous  disorders  may  follow  abortion. 
Case  of  tetanus  following  abortion  at 
the  fourth  month.    Brownlee  (New  Eng- 
land Med.  Monthly,  Nov.,  '91). 

Case  of  hemiplegia  following  abortion. 
The  cervix  had  been  dilated  with  tam- 
pons to  remove  an  adherent  portion  of 
the  placenta.  Fenwick  (American  Jour, 
of  Obst.,  Apr.,  '91). 

Case    in   which,    twelve   days    after    a 
supposed  artificially  produced  abortion,  a 
30-year-old  woman  suffered  from  trismus 
and   tetanus,   the   convulsions   being   se- 
vere and  frequent.     Successful  treatment 
by  means  of  antitoxin.     Ch.  F.  Withing- 
ton    (Boston  Med.  and  Surg.  Jour.,  vol. 
cxxxiv.  No.  3,  '96). 
Etiology. — The  causes  of  abortion  may 
be  due  to  disorders  affecting  the  father, 
the  mother,  or  the  fcetus  itself. 

Analysis  of  a  large  number  of  cases  of 
abortion  occurring  in  the  author's  prac- 
tice gives  the  following  conclusions: 
Habitual  abortion  gives  18.6  per  cent, 
of  the  whole.  Uterine  diseases  cause  50 
per  cent,  of  the  abortions.  Reflex  causes, 
either  simple  or  complicated,  exist  in  21.5 
per  cent.  Syphilis  affecting  the  foetus, 
retroflexion,  salpingitis,  and  rheumatism, 
each  7.1  per  cent.  There  were  78.5  per 
cent,  that  subsequently  bore  children, 
and  21.5  remained  sterile.  Of  these,  14.3 
per  cent,  have  Incurable  uterine  affec- 
tions or  are  past  child-bearing,  and  7.2 
are  healthy,  but  sterile.  Leith  Napier 
(Satellite  of  the  Annual,  Feb.,  '89). 
Paternal  Causes. — Abortion  may  be 
due  to  the  following  paternal  influences: 


ABORTION.     ETIOLOGY. 


43 


Advanced  age;  lowered  vitalitj',  due  to 
overwork  or  excesses,  especially  venereal; 
to  syphilis  and  tuberculosis;  and  to  nox- 
ious influences,  such  as  lead  poisoning 
and  alcoholism. 

Three  cases  of  frequent  abortions,  due 
to  lead  poisoning  from  service-pipes, 
■which  ceased  when  the  cause  was  re- 
moved. Swan  (Brit.  Med.  Jour.,  Feb.  16, 
'S9). 

Case  of  a  37-year-old  X^TII-para,  who 
has   aborted   in   the   last   sixteen   preg- 
nancies at  between  the  fourth  and  the 
seventh  months,  after  her  husband  be- 
came a  house-painter,  and  soon  after  de- 
veloped lead  colic,  followed  by  paralj'tic 
symptoms.    She  seemed  free  from  any  of 
the  symptoms  from  which  her  husband 
suffered,  and  had  not  been  subject  to 
either  tubercle,  syphilis,  or  alcoholism. 
Before  her  husband  had  become  a  painter 
she  had  given  birth  to  two  healthy  chil- 
dren.    Daniel  (Journal  d'Aecouehement, 
May  17,  '96). 
Maternal  Causes.  —  Similar  causes 
to  those  mentioned  for  the  father  act  in 
the  mother,  and  with  more  certainty  if 
both  parents  are  affected  by  them. 

In  addition  the  following  noxious 
influences  are  to  be  noted:  Tobacco 
(women  employed  in  tobacco  manufac- 
tories), carbon  disulphide  (women  em- 
ployed in  India-rubber  works),  and  car- 
bonic oxide.  To  this  latter  agent  is  due 
the  frequency  of  abortion  in  cooks, 
whose  profession  causes  them  to  breath 
this  deleterious  gas  during  a  portion  of 
the  day. 

Bad  hygienic  surroiindings,  especially 
insuiEcient  food,  frequently  promote 
abortion,  while  overfeeding  and  obesity 
(Stoltz)  may  also  act  as  etiological  fac- 
tors. 

Among  local  causes  fibromyomata  of 
the  uterus  and  deviations  (especially  re- 
troversion) are  the  most  frequent  causes. 
Congestion  of  the  uterus  is  a  more  im- 
portant factor  than  retrofle.xion.     Leith 
Napier  (Brit.  Med.  Jour.,  Dec.  20,  '90). 
The   predisposition   to   miscarriage   in 


certain  women  is  due  to  retroversion. 
Excellent  results  obtained  from  the  use 
of  pessaries  when  a  miscarriage  seemed 
imminent.  Henry  Coe  (Int.  Jour,  of 
Surg.,  May,  '92). 

Two  causes  of  successive  abortions 
merit,  in  particular,  the  attention  of  the 
obstetrician:  (1)  uterine  affections,  and 
retroversion  in  particular;  (2)  syphilis. 
Schuhl  (Nouv.  Arch.  d'Obst.  et  de  Gyn., 
Feb.,  '92). 

Analysis  of  235  cases  with  reference  to 
the  causes.  Syphilis  is  the  most  impor- 
tant cause,  and  accounts  for  27  per  cent, 
of  the  eases;  retroflexion  of  the  uterus 
is  accountable  for  IS  per  cent.;  chronic 
metritis  and  endometritis,  10  to  15  per 
cent. ;  uterine  fibroids,  4.7  per  cent. ;  ab- 
normal conditions  of  the  placenta,  4  per 
cent.:  anteflexion  of  the  uterus,  3.5  to 
6  per  cent. ;  molar  pregnancy,  1  per  cent. ; 
Bright's  disease  and  lateral  deviations  of 
tne  uterus,  0.5  per  cent.  Romlield  (Cent, 
f.  Gyn.,  No.  39.  '95) . 

Distinct  local  uterine  conditions  in 
otherwise  healthy  women:  1.  Hi-devel- 
oped uterus:  the  muscular  coat  does 
not  readily  soften,  yet  remains  very  irri- 
table. Rare.  2.  Displacements,  especially 
flexions.  Spur  at  the  angle  of  flexion 
hypertrophies  interferes  with  uterine  de- 
velopment. 3.  Congestion  of  the  body 
and  cervix,  due  to  idiosyncrasies.  Endo- 
metritis. Charpentier  (Ann.  de  Gyn.  et 
d'Obstet.,  May,  '97). 

Lacerations  of  the  cervix,  especially 
those  of  some  depth,  are  a  frequent 
cause  of  abortion.  A  primipara  can 
usually  give  some  cause  for  an  abortion, 
such  as  a  misstep  or  a  fall,  but  in  those 
who  have  previously  borne  children, 
where  there  is  a  fissure  extending  as  high 
as  the  internal  os  that  will  admit  the 
tip  of  the  index  finger,  or  the  integrity 
of  the  lower  uterine  segments  is  lost, 
predisposition  to  abortion  is  undoubted. 
E.  W.  Rogers  (Montreal  Jled.  Jour., 
April.   1902). 

Extensive  laceration  of  the  cervix,  the 
foetus  in  such  a  case  not  being  sustained 
from  below.    (Olshausen,  Schwartz.) 

Old  peritoneal  lesions  of  the  adnexa, 
especially  ovarian  cysts,  come  next  in 
order  as  local  etiological  factors. 


44 


ABORTION.     ETIOLOGY. 


Genital  Excesses. — These  act  espe- 
cially by  mechanical  means.  Yonng 
married  women  frequently  abort  five  or 
six  weeks  after  conception,  on  this  ae- 
eoimt,  while  abortion  is  frequent  among 
prostitutes  for  the  same  reason.  (Parent 
Duchatelet.) 

Acute  oe  chronic  general  diseases, 
acting  either  by  excess  of  temperature 
and  changes  in  the  composition  of  the 
blood  or  by  alterations  in  the  placenta. 

Typhoid  Fever.  —  Abortion  occurs  in 
about  two-thirds  of  the  cases  of  typhoid 
fever,  and  is  more  apt  to  take  place  dur- 
ing the  earlier  than  the  later  months  of 
pregnancy. 

Enteric  fever  materially  influences  the 
course  of  gestation,  since  abortion  occurs 
in  something  like  two-thirds  of  the  cases. 
Thus,  Sacquin  collected  310  cases,  and 
found  abortion  in  199;  while  Martinet 
found  66  abortions  in  109  cases.  W.  For- 
dyce  (Brit.  Med.  Jour.,  Feb.  19,  '98). 

The  most  prominent  feature  is  uter- 
ine haemorrhage,  which  is  often  the  first 
symptom  of  impending  abortion.  The 
use  of  ergot  is  to  be  avoided  in  cases  of 
pregnancy  occurring  in  conjunction  with 
typhoid  fever.  Other  remedies,  such  as 
cold  baths  or  even  quinine,  may  be  safely 
used.  The  history  and  treatment  of  the 
typhoid  state  proper  remain  unaffected 
by  the  co-existing  pregnancy. 

Pneumonia. — During  the  first  months 
of  pregnancy  abortion  occurs  in  more 
than  one-third  of  the  eases  of  pneu- 
monia, but  this  complication  occurs  with 
increasing  frequency  the  more  advanced 
the  pregnancy.  Taking  a  general  aver- 
age of  cases  of  abortion  occurring  during 
pneumonia,  an  estimate  placing  it  at 
two-thirds  of  the  cases  is  probably  cor- 
rect. The  foetus  itself  may  suffer  from 
pneumonic  infection,  and  die  soon  after 
birth  from  pulmonary,  meningeal,  endo- 
cardial, or  other  lesions. 


Statistics  of  213  cases  of  pneumonia 
during  pregnancy:  In  118  cases  the  preg- 
nancy was  interrupted,  there  being  42 
abortions  and  76  premature  deliveries. 
Death  of  the  mother  occurred  in  75  cases 
among  the  213  :  a  mortality  of  35  per 
cent.  The  mortality  of  the  mother  is 
greater  in  premature  deliveries  than  in 
abortion.    S.  Flatte  (These  de  Paris,  '92). 

Influenza.  —  It  is  probable  that  the 
marked  nervous  phenomena  play  a  lead- 
ing part  in  the  production  of  abortion. 
The  vasomotors  bear  the  brunt  of  the 
toxic  effects  in  the  majority  of  cases,  and 
the  secondary  results  of  vasomotor  dis- 
turbance in  the  uterus,  which  is  richly 
supplied  with  vessels,  are  obvious. 

Report  of  a  number  of  abortions  or 
premature  deliveries  resulting  from  in- 
fluenza. Trossat  (Lyon  Med.,  Mar.  11, 
'90). 

Doubt  whether  abortion  and  premature 
labor  in  influenza  depend  upon  mechan- 
ical irritation  from  coughing  and  hyper- 
iemia,  with  local  congestion.  It  is  very 
probable  that  in  such  cases  the  cause  is 
infection  from  the  uterine  mucosa.  Case 
of  abortion  occurring  during  influenza  in 
a  girl  19  years  old;  phlegmasia  alba 
dolens  developed  three  days  after  con- 
finement, followed  on  the  fifteenth  day 
by  pyaemie  abscesses  in  the  sternal  region. 
Labadie-Lagrave  (La  Med.  Mod.,  Feb.  25, 
'92). 

Measles. — This  disease  seldom  occurs 
during  pregnancy.  According  to  some 
authorities  measles  and  pregnancy  have 
but  little  reciprocal  influence.  Of  eleven 
cases  collected  by  Klotz,  however,  nine 
were  attended  by  premature  delivery. 

The  influence  of  measles  is  but  slight 
during  the  first  months  of  pregnancy, 
and  increases  in  gravity  with  the  age  of 
the  pregnancy,  the  occurrence  of  this 
disease  in  childbed  being  generally  fatal. 
Besides  the  danger  of  puerperal  haem- 
orrhage, pneumonia  is  a  frequent  and 
formidable  complication. 

Scarlet   Fever.  ■ —  This    disease    rarely 


ABORTION.    ETIOLOGY. 


45 


complicates  pregnancy,  although  it  is 
comparatively  frequent  in  the  puerperal 
state.  The  period  of  invasion  being  fre- 
quently absent,  it  is  probable,  however, 
that  it  remains  unrecognized,  and  that 
a  larger  proportion  of  cases  of  premature 
birth  and  abortion  are  caused  by  it  than 
is  generally  supposed.  In  some  cases  the 
stage  of  incubation  is  prolonged  to  such 
a  degree  that  the  scarlet  fever  contracted 
during  pregnancy  is  recognized  only 
after  delivery  by  the  sudden  develop- 
ment of  the  eruption  over  the  entire 
body.  Of  8  pregnant  women  suffering 
from  scarlet  fever,  6  who  were  from  4 
to  6  months  with  child  recovered  with- 
oiit  accident,  1  aborted  at  3  months,  and 
1  had  a  premature  delivery  at  7  months 
(Legendre).  The  cases  are  generally 
characterized  by  high  fever,  emesis, 
marked  congestion  of  the  face,  and  sud- 
den appearance  of  the  eruption,  which 
occasionally  assumes  a  livid  color. 

Small-pox.  —  This  disease  manifests  a 
preference  for  women  in  whom  the  preg- 
nancy is  not  far  advanced,  but  proves 
much  more  dangerous  when  it  occurs 
near  the  parturient  state.  It  attacks 
pregnant  women  oftener  than  any  other 
disease.  The  probability  of  abortion 
varies  with  the  intensity  of  the  process 
present.  Varioloid  causes  abortion  in 
about  one-tenth  of  the  cases  attacked 
(Mayer).  Discreet  variola  causes  abor- 
tion in  about  one-half  the  cases,  while 
in  confluent  variola  and  hemorrhagic 
variola  abortion  nearly  always  occurs, 
especially  if  the  pregnancy  be  advanced. 

The  foetus  may  be  expelled  during 
either  one  of  the  stages:  invasion,  erup- 
tion, or  suppuration.  It  may  present 
characteristic  variolous  cicatrices:  Occa- 
sionally the  child  remains  unaffected;  it 
may  also  suffer  from  the  disease  before 
or  soon  after  birth,  the  mother  remain- 
ing immune. 


Among  72  cases  of  small-pox  in  preg- 
nant women,  31  miscarriages  and  20 
deaths.  Sangregorio  (Med,  Standard, 
May,  '88). 

Abortion  occurring  during  variola  is 
usually  attended  with  more  than  the 
ordinary  amount  of  hseraorrhage.  Gas- 
parini  (Gaz.  Med.  Lombarda,  No.  18,  '92; 
I'Union  Med.,  July  5,  '92). 

Several  serious  cases  occurring  during 
convalescence  after  small-pox.  The  grave 
symptoms  are  due  to  the  retention  of 
the  fffitus,  which  has  died  during  the 
acute  stage  of  small-po.\,  and  which  is 
frequently  only  expelled  during  or  after 
convalescence.  Arnaud  (Gaz.  des  Hop., 
July  28,  '92). 

Cholera.  —  Women  are  the  most  sus- 
ceptible to  this  disease  ditring  the  later 
period  of  pregnancy.  Abortion  almost 
always  occurs,  even  in  comparatively 
slight  attacks,  and  the  prognosis  for 
mother  and  child  is  most  unfavorable. 
The  abortion  has  been  ascribed  to  uter- 
ine contractions,  to  acute  hsmorrhagic 
endometritis,  and  to  disturbance  of  the 
foetal  circulation  caused  by  the  thicken- 
ing of  the  blood.  It  is  probable  that 
these  three  factors  are  present  simulta- 
neousl)',  in  addition  to  placental  granu- 
lar degeneration,  which  cause  the  death 
of  the  foetus. 

Icterus. — This  disorder  rarely  presents 
itself  ditring  pregnancy.  It  may  occur 
in  three  forms: — 

(a)  Simple  catarrhal  icterus,  in  which 
abortion  frequently,  though  not  always, 
occurs;  (b)  icterus  gravis,  in  which  abor- 
tion always  occurs,  and  is  almost  invari- 
ably fatal;  and  (c)  the  epidemic  icterus, 
peculiar  to  pregnant  women,  which  causes 
abortion  in  the  great  majority  of  cases. 

Icterus  presents  a  peculiar  feature  that 
renders  it  important  in  connection  with 
pregnancy:  i.e.,  its  tendency  to  either 
precede  or  accompany  the  fatal  patho- 
logical changes  attending  yellow  atrophy 
of  the  liver.     Pregnancy  exerts  a  perni- 


46 


ABORTION.    ETIOLOGY. 


cious  influence  upon  the  course  of  even 
simple  icterus,  owing  probably  to  the 
obstruction  afforded  not  only  to  hepatic 
circulatory  functions,  but  also  those  of 
the  kidneys.  This  would  tend  to  cause 
reabsorption  of  the  biliary  acids  and  to 
produce  yellow  atrophy.  Fatal  icterus 
during  pregnancy  is  also  due  occasion- 
ally to  the  lesions  attending  phosphorus 
poisoning. 

Malaria  does  not  frequently  compli- 
cate pregnancy,  but  causes  abortion  in 
about  one-half  of  the  cases  attacked. 
Pregnancy  seems  occasionally  to  cause 
a  relapse  in  women  apparently  cured  of 
malarial  fevers.  On  the  other  hand, 
parturition  suspends  periodical  parox- 
ysms, in  a  large  proportion  of  the  cases, 
for  two  or  three  weeks.  The  malarial 
paroxysms  occurring  during  pregnancy 
are  characterized  by  irregularity,  and 
the  foetal  movements  may  be  suspended 
while  the  paroxysm  lasts.  Quinine  may 
safely  be  given  even  in  large  doses,  which 
best  control  the  febrile  phenomena.  The 
ease    is    different    in    habitual    abortion 

Action  of  quinine  on  pregnant  women. 
In  49  pregnancies  quinine  was  used  in 
47,  tlie  patients  suffering  more  or  less 
severely  from  malarial  fever.  Of  these, 
47  cases  terminated  at  the  usual  period 
by  the  birth  of  a  child,  and  2  aborted. 
In  these  2  cases  it  is  extremely  probable 
that  the  high  fever  from  which  they 
suffered  was  instrumental  in  producing 
abortion.  Medicinal  doses  of  quinine 
are  poM'erless  to  induce  abortion.  The 
drug  may  be  safely  given  in  therapeutic 
doses  during  pregnancy.  0.  Frederici 
(La  Clinica  Ostetrica,  April,  1902). 

Chorea  rarely  occurs  as  a  complica- 
tion, and  especially  affects  primiparse. 
It  causes  abortion  in  about  one-half  of 
the  serious  cases,  and  the  exhaustion 
consequent  upon  the  violent  muscular 
movements  occasionally  proves  fatal  to 


the  mother.  The  child,  when  parturition 
is  approaching,  may  not  be  lost  with  the 
mother,  but  it  is  frequently  affected  with 
chorea.  In  a  small  proportion  of  cases  of 
chorea  paroxysms  cease  at  the  beginning 
of  parturition. 

Syphilis. — Whether  contracted  at  the 
beginning  or  during  the  course  of  preg- 
nancy, syphilis  gives  rise  to  very  marked 
and  widely  spread  initial  symptoms, 
while  the  subsequent  symptoms  are  mild. 

When  syphilis  is  contracted  previous 
to  conception,  abortions  occur  repeat- 
edly; but,  as  with  time  the  date  of 
the  infection  becomes  more  remote,  the 
abortions  occur  at  a  later  date  in  the 
course  of  the  pregnancy,  until  premature 
delivery  may  occur,  and  finally  delivery 
at  term. 

When  conception  and  infection  occur 
simultaneously,  abortion  is  almost  con- 
stant if  no  treatment  be  given;  if  imme- 
diate treatment  be  instituted  the  chances 
of  abortion  are  somewhat  reduced. 

When  infection  occurs  after  concep- 
tion has  taken  place,  the  nearer  the  two 
dates  of  conception  and  infection  are 
to  each  other,  the  more  will  abortion  be 
likely  to  occur.  A  thorough  mercurial 
treatment  should  be  inaugurated  as  soon 
as  the  presence  of  syphilis  is  known. 

Diabetes.  —  This  disease  may  compli- 
cate pregnancy  either  on  account  of  its 
presence  before  conception,  or  it  may 
occur  during  pregnancy  only.  Abortion 
occurs  in  about  one-third  of  the  cases, 
one-fourth  of  these  ending  fatally,  gen- 
erally by  collapse.  The  child,  though 
viable,  usually  perishes.  This  complica- 
tion presents  itself  almost  invariably  in 
multiparffi. 

Disease  of  the  Heart.  —  The  influence 
of  cardiac  disease  upon  pregnancy  varies 
with  the  character  and  seat  of  the  affec- 
tion that  may  be  present.  Generally 
speaking,  however,  abortion  and  prema- 


ABORTION.    ETIOLOGY.    PROGNOSIS. 


47 


ture  delivery  are  frequently  observed: 
i.e.,  in  about  two  eases  out  of  every  five 
of  heart  trouble. 

While  acute  pericarditis  seems  to  bear 
practically  no  influence  iipon  the  normal 
course  of  the  gestation,  chronic  peri- 
carditis is  a  pernicious  accompaniment 
of  pregnancy,  owing  to  the  insufficient 
compensation  afforded  by  the  heart  itself 
for  pre-existing  valvular  lesions  to  satisfy 
the  increased  demand  upon  that  organ. 
Acute  endocarditis  assumes  increased 
dangers  during  pregnancy  through  a 
marked  tendency  to  assume  an  ulcerative 
process^  which  generally  ends  fatally. 

Mitral  lesions,  especially  mitral  steno- 
sis and  insufficiency,  are  considered  by 
Germain  See  and  Porak  as  the  cardiac 
disorders  most  likely  to  cause  death  of 
the  patient.  If  slight,  however,  or  en- 
tirely compensated  for,  the  parturition 
may  occur  without  trouble.  Intense 
passive  pulmonary  congestion,  oedema, 
ascites,  and  metrorrhagia  are  to  be 
feared  in  all  such  cases.  Aortic  insuffi- 
ciency or  stenosis  is  generally  most 
marked  in  advanced  pregnancy  on  ac- 
count of  increased  arterial  tension,  but 
these  untoward  symptoms  frequently 
disappear  after  parturition. 

Pulmonary  Diseases.  —  In  the  great 
majority  of  instances  pregnancy  hastens 
the  development  of  phthisis,  and  pre- 
cipitates its  progress.  In  women  predis- 
posed to  phthisis  the  probabilities  as  to 
the  occurrence  of  this  disease  are  thus 
increased  by  marriage.  Although  they 
sometimes  escape  it  during  the  first  preg- 
nancy, the  likelihood  that  the  disease 
will  show  itself  in  future  pregnancies 
is  nevertheless  great.  Abortion  or  pre- 
mature delivery  is  frequent  in  these 
cases,  and  the  viability  of  the  child  is 
proportionate  to  the  condition  of  the 
mother.  Every  effort  should  be  made  to 
thoroughly  nourish  such  eases,  overfeed- 


ing, milk,  etc.,  forming  the  basis  of  the 
measures  to  be  instituted. 

Chronic  pleurisy,  empyema,  and  em- 
physema are  liable  to  produce  dilatation 
of  the  heart  and  thus  render  it  inca- 
pable of  compensating  for  the  increased 
arterial  tension  of  the  parturient  state. 
These  conditions,  however,  are  more 
dangerous  to  the  mother  than  to  the 
child;  indeed,  abortion  under  such  cir- 
cumstances sometimes  saves  the  patient's 
life. 

TRAUMATisii.  —  Brutal  treatment  of 
pregnant  women,  falls,  etc.,  are  well- 
known  causes.  The  farther  removed 
from  the  genital  organs  is  any  trauma- 
tism the  less  likelihood  is  there  of  abor- 
tion being  produced.  Even  small  oper- 
ations— the  opening  of  an  abscess,  the 
extraction  of  teeth,  etc. — have  caused 
abortion. 

Case  of  abortion  caused  by  the  extrac- 
tion of  a  tooth  thirteen  days  before. 
Labor  Avas  immediately  preceded  by 
severe  haemorrhage  from  the  dental  al- 
veolus. Poyntz  (Indian  Med.  Record, 
Feb.,  '91). 

Abortion  may  be  due  to  too  frequent 
pregnancies.  Among  other  well-known 
causes  may  be  cited  long  Journeys  or 
short  joitrneys  too  frequently  repeated; 
excessive  walking,  climbing,  riding,  or 
other  physical  exercise;  falls,  moral 
shocks,  etc. 

Causes  Due  to  the  Fcetus  or  Mem- 
branes.— Degeneration  of  the  villosities 
of  the  chorion,  hydramnion,  and  vicious 
insertion  of  the  placenta  are  the  main 
causes  of  abortion  due  to  abnormalities 
of  the  foetus  and  the  secundines. 

Prognosis. — The  embryo,  or  foetiis,  al- 
ways perishes;  the  prognosis,  therefore, 
only  applies  to  the  mother.  Cases  of 
spontaneous  uncomplicated  abortion  al- 
most always  recover  with  proper  care. 
The  cause  of  the  abortion,  the  date  of 
the  pregnancy,  the  degree  of  antisepsis 


ABORTION.     PROGNOSIS.     DIAGNOSIS. 


employed,  or  the  previous  cleanliness 
observed  by  the  patient  all  bear  influence 
upon  the  final  issue  of  the  case. 

In  Pinard's  service  the  mortality  of 
abortions  was  0.81  per  cent.;  of  abortions 
having  begun  outside  the  service,  37.5 
per  cent.  At  Bellevue  Hospital  no  case 
of  death  has  occurred  since  it  has  become 
customary  in  that  institution  to  empty 
the  uterus  in  every  case  of  incomplete 
abortion.  Out  of  926  cases  noted  by 
Hirst  there  were  13  deaths:  a  mortality 
of  1.4  per  cent. 

As  to  the  mortality  of  the  product  of 
conception,  out  of  434  cases  in  Pinard's 
service,  the  foetus  was  born  alive  in  221, 
dead  and  macerated  in  199,  and  died 
during  delivery  in  14  cases. 

In  abortion  due  to  syphilis  the  foetus 
is  almost  always  dead  and  macerated;  in 
abortion  due  to  vicious  insertion  of  the 
placenta,  almost  always  alive;  in  albu- 
minuria in  about  equal  proportions. 

Involution  of  the  uterus  is  usually 
more  rapid  than  after  normal  delivery, 
on  account  of  the  lesser  size  of  the 
uterus.  Incomplete  delivery  may  be  a 
cause  of  imperfect  involution.  Patients 
should  be  kept  in  bed  ten  days.  Metri- 
tis is  likely  to  be  the  sequel  of  abortion 
-when  the  patient  is  allowed  to  leave  her 
bed  too  soon.  The  influence  of  perfect 
involution  on  future  pregnancies  is 
marked. 

A  woman  may  lose  immense  quanti- 
ties of  blood  in  a  threatened  abortion, 
appear  moribund  from  exsanguination, 
and  yet  rally  and  go  on  to  full  term 
under  appropriate  measures. 

Diagnosis.  —  Pain,  haemorrhage,  dila- 
tation of  the  cervix,  and  descent  of  the 
ovum  are  the  characteristic  features  of 
abortion  which  easily  distinguish  it  from 
other  disorders. 

Dtsmenorehcea  may  be  mistaken  for 
-impending  miscarriage.    In  this  disorder 


the  cervix  is  closed  and  firm  and  the  pain 
precedes  hsemorrhage.  In  abortion,  on 
the  contrary,  the  cervix  is  open  and  soft 
and  the  hemorrhage  usually  precedes 
the  pains. 

Ohganic  lesions  of  the  cervix — 
such  as  tumors,  etc. — sometimes  give  rise 
to  hsemorrhages;  but  the  history  of  the 
case  and  a  careful  local  examination  will 
generally  establish  the  nature  of  the 
condition  present.  A  soft  polypus  may, 
however,  resemble  a  small  ovum,  and 
increase  the  diiBculty. 

Hepatic  colic  and  nephritic  colic 
sometimes  simulate  labor-pains,  but  the 
absence  of  hsemorrhage  from  the  vagina, 
and  the  intensity  of  the  suffering,  soon 
establish  the  identity  of  these  diseases. 

Threatened  abortion  being  the  condi- 
tion present,  the  next  point  is  to  ascer- 
tain whether  the  abortion  is  inevitable. 

Abortion  is  inevitable  (1)  when  the 
membranes  are  ruptured,  (2)  when  the 
foetus  is  dead,  or  (3)  when  any  foetal 
part  is  already  engaged  in  the  cervix 
(Auvard).  So  long  as  symptoms  of  these 
three  conditions  are  not  present,  abor- 
tion may  not  occur. 

When  symptoms,  such  as  hsemorrhage, 
have  occurred,  it  is  often  difficult  to 
determine  whether  abortion  has  really 
taken  place,  and,  if  so,  whether  it  is 
incomplete  or  complete.  Uterine  explo- 
ration may  then  become  necessary. 

During  the  first  weeks  of  pregnancy 
the  embryo  may  be  so  small  as  not  to 
be  easily  found,  and  a  positive  diagnosis 
may  not  be  established  until,  by  subse- 
quent events,  continuation  of  pregnancy 
or  involution  of  the  uterus  takes  place. 
When  the  foetus  is  dead  it  may  remain 
in  the  uterus  and  the  latter  be  thought, 
by  the  attending  physician,  to  be  empty. 
In  some  cases,  even  after  hsemorrhages 
and  the  expulsion  of  portions  of  the 
secundines  have  taken  place,  the  inter- 


ABORTION.    DIAGNOSIS.    TREATMENT. 


49 


ruption  of  pregnancy  has  only  been 
apparent. 

Tubal  abortion  may  simulate  common 
abortion.  The  ovum  is  not  invariably 
expelled  from  the  o-stimn  of  the  tube 
and  discharged  into  the  uterus.  Case 
in  which  a  complete  decidua  was  dis- 
charged, the  ovum  being  subsequently 
e.xpelled.  The  diagnosis  was  supported 
by  the  detection  of  a  thickening  of  the 
right  cornu.  Skutsch  (Centralb.  f.  Gyn., 
No.  25,  '97). 

Spurious  abortion.  A  class  of  cases  in 
which  a  mimicry  of  early  pregnancy  and 
of  abortion  occurs  quite  different  in  its 
characters  from  the  condition  known  as 
"spurious  pregnancy."  They  are  not 
associated  with  hysteria,  and  the  usual 
functional  disturbances  of  pregnancy 
are  not  exaggerated.  They  differ  from 
pseudocyesis  in  the  existence  of  definite 
changes  in  the  uterus,  and  from  preg- 
nancy, either  topic  or  ectopic,  in  the 
essential  point  of  the  absence  of  an 
ovum,  a  mimic  abortion:  in  the  occur- 
rence of  a  period  of  amenorrhoea  with 
enlargement  of  the  uterus  and  forma- 
tion within  it  of  a  body,  the  detachment 
and  expulsion  of  which  is  followed  by  a 
return  to  menstrual  regularity  and  the 
former  condition  of  general  health.  The 
body  expelled  is  not  an  ovimi,  but  is 
formed  entirely  from  menstrual  struct- 
ures.    Three  cases  recorded. 

A  membrane  having  the  essential 
characters  of  the  decidua  of  pregnancy. 
Diagnosis  impossible  until  after  the  dis- 
charge of  the  cast.  T.  W.  Eden  (Lon- 
don Lancet,  Sept.  25,  '97). 

Tubal  abortion  and  operation.  A  low 
mortality  follows  removal  of  a  gravid 
tube  in  early  pregnancy,  when  there  are 
s^inptoms  of  internal  haemorrhage.  On 
the  other  hand,  a  good  number  of  diffuse 
intraperitoneal  haemorrhages  do  not  kill, 
but  end  in  the  formation  of  an  hae- 
matocele.  Prognosis  is  very  uncertain, 
and  any  case  may  end  fatally.  An  ex- 
ploratory incision  through  the  vagina  is 
advised,  preparations  being  made,  in  any 
case,  for  abdominal  section.  The  escape 
of  blood-clot  and  broken-down  tissue 
when  Douglas's  pouch  is  opened  con- 
firms the  diagnosis  of  tubal  abortion. 
The  uterus  and  tubes  can  then  be  e.x- 

1- 


plored  with  the  finger.  If  the  tube  is 
found  ruptured,  abdominal  section  is 
required;  if  there  is  simple  and  com- 
plete tubal  abortion  into  the  peritoneal 
cavity,  Douglas's  pouch  should  be 
drained.  When  the  expulsion  is  incom- 
plete, or  there  is  a  tubal  mole,  the  ovum 
being  retained  in  the  tube,  abdominal 
section  and  removal  of  the  tube  are  in- 
dicated. Spinelli  (Archivio  Ital.  di 
Ginec,  .June,  1901). 

Treatment. 

Theeatened  Abortion.  —  Absolute 
mental  and  physical  rest  is  imperatively 
demanded.  The  patient  should  be  kept 
in  bed,  with  her  hips  slightly  elevated, 
and  be  given  only  light  and  cool  food. 

To  arrest  the  uterine  contractions 
tincture  of  opium,  12  drops  every  two 
hours,  may  be  given  by  the  mouth;  or 
extract  of  opium,  1  grain  in  a  supposi- 
tory, every  three  hours.  If  the  pain  is 
severe,  morphia,  ^/^  grain,  and  atropia, 
Vso  grain,  should  be  administered  hypo- 
dermically.  Laudanum  enemata,  25 
drops  to  ^/„  pint  of  water,  are  also  ef- 
fective. If  an  idiosyncrasy  preclude  the 
use  of  opium,  chloral-hydrate,  10  grains, 
and  bromide  of  potassium,  20  grains, 
every  two  hours,  then  every  three  hours, 
may  be  used  instead. 

A  good  method  is  to  administer  opium, 
one-half  of  the  dose  under  the  form  of 
laudanum  enemata  and  the  other  half 
as  subcutaneous  injections  of  morphine 
(Eibemont).  Constipation  from  the  ef- 
fect of  the  opium  is  to  be  avoided. 

The  fluid  extract  of  viburnum  pruni- 
f  olium,  ^/s  to  1  drachm  every  three  hours 
or  10  drops  every  half-hour,  with  chloral 
hydrate,  8  grains,  is  valuable  to  arrest 
titerine  contractions  when  opium  cannot 
be  used  on  account  of  its  constipating 
tendency. 

The  tincture  of  viburnum  prunifolium 
is  useful  in  cases  where  the  membranes 
have    been    ruptured    and    the    liquor 


50 


ABORTION.     TREATMENT. 


amnii  discharged,  but  where  there  are 
still  hopes  of  preventing  a  miscarriage. 
It  should  not  be  given,  however,  when 
the  fcetus  is  dead,  when  a  miscarriage 
has  actually  commenced,  or  when  there 
is  any  reason  why  it  is  not  best  that 
birth  should  be  delayed.  Auvard  (Bos- 
ton Med.  and  Surg.  Jour.,  Mar.  22,  '88). 
Viburnum  paralyzes  both  the  centres 
of  voluntary  motion  and  the  reflex  func- 
tions of  the  spinal  cord  without  impair- 
ing sensation  or  consciousness,  and  it  is 
consequently  destined  to  become  an  ap- 
proved remedy  in  all  diseases  character- 
ized by  increased  excitability  of  the 
motor  centres.  The  solid  extract  of  the 
drug  is  recommended,  in  doses  of  from 
5  to  10  grains,  and  the  fluid  extract  in 
doses  of  from  V:  drachm  to  V2  ounce. 
R.  L.  Payne  (Med.  News,  Apr.  2,  '92). 

Inevitable  Abortion. — When  abor- 
tion cannot  be  avoided,  all  the  foregoing 
measures  are  contra-indicated. 

During  the  first  two  months  but  little 
treatment  is  necessary  other  than  rest  in 
bed.  If  no  untoward  symptoms  appear, 
such  as  marked  haemorrhage,  rise  of  tem- 
perature, etc.,  expectant  measures  are 
sufficient,  at  least  for  some  days. 

During  the  third  month  the  ovum 
may  be  expelled  entire,^ — i.e.,  without 
rupture  of  the  membranes.  In  this  case 
no  active  measure  is  required  beyond, 
perhaps,  an  antiseptic  douche, — a  creolin 
2-per-cent.  solution  of  a  weak  carbolic- 
acid  one, — employed  twice  daily. 

When,  in  the  course  of  the  third 
month  the  sac  ruptures  and  the  liquor 
amnii  escapes,  the  sudden  reduction  of 
the  pressure  exerted  by  the  ovum  upon 
the  intra-uterine  surfaces  causes  free 
hemorrhages  from  the  utero-placental 
vessels. 

HamorrJiage.  —  The  treatment  of  the 
ha?morrhage  at  this  period  is  that  for 
the  subsequent  one.  The  patient  being 
placed  in  the  Sims  position,  all  clots  are 
removed  and  the  vagina  is  packed  with 
iodoform  gauze  or  cotton-wool.     If  the 


bleeding  persist,  vaginal  douches  of  hot 
alum  solution,  1  ounce  to  the  pint,  are 
administered.  The  packing  is  then  re- 
newed, and  3  drachms  of  the  fluid  ex- 
tract of  ergot  are  injected  into  the 
rectum.  If  the  bleeding  is  alarming, 
the  uterine  canal  may  be  packed  with 
small  pledgets  of  iodoform  cotton  or 
gauze. 

Whenever  abortion  takes  place  none 
of  the  tissues  should  be  left  in  the 
uterus.  1.  At  4  weeks  best  to  keep  down 
hsemorrhage  and  to  wait  for  nature  to 
act;  if  interference  necessary,  deeidua 
to  be  removed,  using  the  curette.  2.  At 
6  to  8  weeks  chorion  causes  most  trouble; 
finger  or  curette  used  and  strip  of  iodo- 
form gauze  introduced  to  fundus.  3.  At 
10  to  12  weeks  fcetus  comes  first;  other 
tissues  apt  to  need  artificial  removal; 
finger  best;  gauze  as  before;  small  doses 
of  ergot  for  twenty-four  hours.  Edward 
Ayers  (Medical  Record,  Sept.  28,  '95). 

When  fragments  of  placenta  or  other 
adnexa  are  left  in  the  uterus  they  rapidly 
give  rise  to  foul  discharge,  which  may  be 
followed  by  grave  septic  symptoms.  The 
patient  should  at  once  be  placed  in 
the  Sims  position  and  be  given  an  anaes- 
thetic, if  necessary.  The  endometrium  is 
then  thoroughly  cleansed  and  curetted, 
then  washed  out  with  hot  1  to  5000 
corrosive-sublimate  solution.  No  ergot 
should  be  administered  until  the  uterus 
is  thoroughly  emptied.  The  external 
genitals  are  then  carefully  cleansed  and 
a  compress  of  carbolized  cotton  is  applied 
over  the  vulva.  Lysol,  in  1-per-cent. 
solution,  is  highly  recommended  for  in- 
jections in  infectious  cases. 

When  with  closed  os  haemorrhage  is 
profuse,  we  must  no  longer  speak  of 
"threatened,"  but  of  "beginning,"  abor- 
tion. In  cases  like  this,  especially  if  the 
OS  enlarges,  we  cannot  possibly  reckon 
on  saving  the  embryo,  although  this  may 
unexpectedly  occur  in  rare  instances. 
The  third  stage  is  that  of  complete  abor- 


ABORTION.     TREATMENT. 


51 


tion;  persistent  bleeding  usually  denotes 
retention  of  bits  of  membrane,  and  the 
proof  of  retention  is  usually  found  in 
the  patency  of  the  os  to  one  finger.  Ex- 
amination of  the  ovum  is  necessary  to 
determine  the  likelihood  of  the  persist- 
ency of  portions  within  the  uterus.  In 
this  waj',  if  we  find  that  the  integrity 
of  the  expelled  ovum  has  not  suffered, 
we  need  have  no  fear  of  retention.  If 
the  ovum  is  incomplete,  and  htemorrhage 
continues  from  the  uterus,  we  have 
every  warrant  for  emptying  the  uterus 
with  the  curette.  If  the  os  uteri  closes, 
we  may  feel  sure  that  the  remains  of 
decidua  must  be  slight.  With  every 
evidence  of  expelled  ovum  and  closed  os, 
persistent  bleeding  can  be  due  only  to 
atony  of  the  uterus.  Lantos  {Monats. 
f.  Geburts.  u.  Gynak.,  May,  '99). 

If  haste  imperative,  the  cervix  is  di- 
lated and  a  lateral  incision  is  made  in 
the  cervix.  The  uteriis  is  then  emptied 
with  a  blunt,  rounded,  fenestrated 
curette,  followed  by  swabbing.  The 
uterus  is  thus  emptied  without  haemor- 
rhage. The  pain  is  very  slight  and  no 
anaesthetic  is  required.  The  incision  in 
the  cervix  is  at  once  sutured.  This 
method  is  prompt,  sure,  and  safe. 
Dolfiris  (Semaine  Mgd.,  Sept.  5,  1900). 

The  best  method  to  adopt  to  incur 
little  risk  for  the  patient:  No  inter- 
ference is  necessary  in  ordinary  cases 
except  in  eases  of  severe  anaemia  pro- 
duced by  a  profuse  haemorrhage  or  by 
long-continued  slighter  bleeding,  when 
portions  of  the  ovum  are  retained,  and 
in  cases  which  have  become  septic.  The 
most  rational  method  of  arresting 
hsemorrhage  is  to  remove  the  ovum  com- 
pletely. If  this  has  left  the  body  of 
the  uterus,  and  is  retained  partially  or 
totally  in  the  cervix  or  vagina,  a  spec- 
ulum should  be  introduced,  and,  if  the 
finger  cannot  easily  complete  the  re- 
moval, ovum  forceps  may  be  used. 
When  the  ovum  is  still  in  the  body  of 
the  uterus,  one  or  two  fingers  should  be 
introduced,  and — while  counter-pressure 
is  exercised  by  the  other  hand  from 
the  abdominal  wall — the  sac  separated 
completely  from  the  uterine  wall.  Once 
it  has  been  separated,  it  can  usually 
be  removed  by  combined  action  of  the 


internal  finger  and  expression  from 
witliout.  The  whole  process  can  be 
made  more  easy  if  one  seizes  the  an- 
terior lip  of  the  cervix  with  vulsellum 
forceps  (double-toothed),  and  admin- 
isters an  anaesthetic.  The  operator 
must  not  be  disturbed  by  the  haemor- 
rhage, but  must  rely  on  the  fact  that 
this  will  cease  on  completion  of  the 
abortion.  If  the  cervix  is  not  permeable 
for  the  finger,  thorough  plugging  of  the 
uterus,  cervix,  and  vagina  with  sterile 
iodoform  gauze  is  then  indicated.  The 
cervix  is  brought  into  view  with  a  Sims 
speculum  by  means  of  a  uterine  catheter 
or  sound,  and  the  size  of  the  uterus 
by  bimanual  examination,  and  not  by 
the  sound.  The  vagina  is  to  be  thor- 
oughly irrigated,  cleansed,  and  dried, 
and  then  the  strips  of  gauze  introduced 
with  smooth  ovum  forceps.  All  one's 
efl'orts  should  be  directed  toward  keep- 
ing the  ovum  intact.  At  times  it  may 
be  necessarj'  to  substitute  a  sound  for 
the  forceps  in  packing  the  uterus.  If 
the  ovum  is  not  cast  out  after  twenty- 
four  hours,  the  plugging  is  to  be  re- 
moved, the  passage  again  thoroughly 
disinfected,  and  a  second  packing  under- 
taken. Sellheim  (Mtinchener  med. 
Woch.,  March  11,  1902). 

Delayed  Aboetion. — When  this  oc- 
curs prolonged  expectant  treatment 
exposes  the  pati-ent  to  dangerous  heem- 
orrhage  and  septicEemia;  hence  early 
active  measures  are  indicated.  If  the 
adnexa  are  not  expelled  in  twenty-four 
hours,  injections  of  hot  carbolized  water 
into  the  uterus,  between  its  walls  and 
the  ovum,  every  three  hours,  using  a 
Bozeman  catheter,  may  be  employed;  or, 
if  the  haemorrhage  is  controlled  and  the 
OS  is  sufficiently  patent,  the  finger  may 
be  introduced,  then  hooked,  and  the 
uterine  contents  evacuated. 

If  the  os  is  not  dilated,  a  piece  of  iodo- 
form gauze  or  an  iodoform  bougie  can 
be  inserted;  in  from  twelve  to  twenty- 
four  hours  the  finger  can  generally  be 
introduced  and  the  adnexa  removed.  If 
this  is  difficult,  a  blunt  curette  may  be 


52 


ABORTION.    TREATMENT. 


employed  instead  of  the  finger,  prefer- 
ably Thomas's  large  model.  Sims's  sharp 
curette  is  also  highly  recommended.  If 
used  with  due  care  it  is  an  excellent  in- 
strument. 

"When  intervention  is  necessary,  in- 
stead of  the  curette  I  simply  use  my 
finger,  which  is  a  marvelous  instrument 
for  one  possessed  of  intelligence,  while 
the  curette  is  a  blind  instrument  which 
I  only  use  when  there  is  htemorrhage  or 
infection."  For  intra-uterine  injections 
a  solution  of  permanganate  of  potassium 
recommended.  Tarnier  (L'Union  Med. 
du  Can.,  Nov.,  '97). 

To  use  the  finger  as  a  curette  is,  in 
most  cases,  unsatisfactory,  even  when 
one  hand  is  used  for  pressing  the  fundus 
down.  The  finger  is  often  arrested  at 
the  internal  os  or  does  not  reach  the 
uppermost  part  of  the  cavity,  and,  at  all 
events,  it  can  only  be  used  to  separate 
the  ovum  from  the  uterus,  and  cannot 
remove  the  deoidua  vera.  Henry  J.  Gar- 
rigues  (Med.  News,  Nov.  6,  '97). 

Condition  indispensable  and  invariable 
for  the  efficient  and  thorough  use  of  the 
curette  after  abortion,  —  namely:  that 
the  uterine  canal  should  be  sufficiently 
dilated  to  permit  the  index  finger  to 
explore  the  uterine  cavity  to  the  fundus, 
in  order  not  only  to  determine  the  quan- 
tity and  location  of  the  retained  secun- 
dines,  but  also  to  enable  the  operator  to 
be  perfectly  sure  that  the  cavity  has  been 
entirely  emptied  when  the  operation  is 
completed. 

An  empty  uterus  after  abortion  almost 
always  contracts,  and  all  hsemorrhage 
from  its  cavity  ceases.  A  failure  to  con- 
tract at  that  time  is  an  exception.  If 
a  hot  sterilized  or  carbolized  intra-uterine 
douche  is  used  after  emptying  an  abort- 
ing uterus,  prompt  contraction  and  cessa- 
tion of  bleeding  takes  place.  Only  in 
women  very  much  exhausted  from  haem- 
orrhage might  it  be  advisable  to  pack 
the  empty  uterus  after  abortion  with 
iodoform  gauze,  or,  better,  sterilized 
gauze,  in  order  to  save  her  even  the  few 
drops  of  blood  which  would  ooze  away 
during  the  first  day  or  two,  until  she 
has  rallied.  Paul  F.  Mund&  (Med.  News, 
Nov.  27,  '97). 


Case  in  which  patient  had  been  curetted 
on  two  occasions  to  remove  remains  of 
incomplete  abortion.  At  second  opera- 
tion, failing  to  remove  all  placental  tis- 
sue with  curette,  uterine  cavity  was 
plugged,  and,  after  forty-eight  hours, 
finger  introduced  and  remaining  portions 
removed.  Severe  haemorrhage  led  to  ex- 
tirpation of  uterus.  On  microscopical 
examination,  material  removed  by  curette 
proved  presence  of  muscular  tissue. 
Conclusion  that  placenta  in  this  case 
must  have  been  abnormally  adherent,  and 
uterine  wall  abnormally  soft,  and  that 
the  finger  is  a  better  instrument  than 
curette  in  imperfect  abortion.  Duhrssen 
(Berl.  Med.  Soc,  May,  '98). 

This  treatment,  if  applied  sufficiently 
early,  causes  a  reduction  of  temperature. 
Within  an  hour  or  two  a  chill  may 
indicate  slight  absorption  of  infectious 
elements  through  the  vessels  laid  open 
during  the  operation;  but  rapid  improve- 
ment usually  follows. 

When  the  curette  is  used  the  softened 
condition  of  the  uterine  tissue  should 
be  borne  in  mind;  death  from  perfora- 
tion has  been  reported.     (Alberti,  Long, 

Many  accidents  have  been  attributed 
to  the  curette.  Eecamier  reported  three 
cases  from  perforation  of  the  uterus  by 
his  curette;  Dumarquay  two;  Chamber- 
lain had  a  case  of  hysterical  tetanus; 
Peaslee,  a  death  from  collapse;  Thomas, 
a  narrow  escape  from  the  same  cause; 
and  Parker,  a  case  of  peritonitis.  But 
in  these  cases  it  was  not  the  Sims  sharp 
curette.  It  should,  of  course,  be  handled 
with  ordinary  common-sense  in  order 
not  to  cut  too  deeply  and,  perhaps,  per- 
forate the  uterine  wall.  Personally  used 
in  a  large  number  of  cases  without  acci- 
dent. Goldberg  (Buffalo  Med.  Jour., 
Aug.,  '97). 

In  99  cases  (out  of  275)  requiring 
operative  interference,  55  were  treated 
by  digital  exploration  and  removal  of 
fragments,  and  44  eases  were  treated  by 
curetting.  In  this  series  of  eases  6  deaths 
occurred.  In  2  cases,  at  the  autopsy,  a 
perforation    was    found    at    the    fundus 


ABORTION.     TREATMENT. 


53 


uteri,  with  peritonitis.  Both  cases  were 
already  infected  before  reaching  the  hos- 
pital. In  1  curettage  had  been  carefully 
performed;  in  the  other  the  uterus  had 
merely  been  packed  with  gauze.  The 
third  fatal  result  was  due  to  suppurative 
salpingitis,  operated  upon  after  leaving 
the  hospital.  The  3  remaining  deaths 
were  due  to  infection,  the  patients 
arriving  at  the  hospital  with  grave  sep- 
tic symptoms.  Maygrier  (L'Obstfitrique, 
July,  '97). 

Antiseptic  douches  are  important  to 
remove  what  detritus  may  remain  behind 
a  3-per-cent.  carbolic-acid  solution  from 
the  endometrium  after  curetting. 

Packing  of  the  itterine  cavity  with 
iodoform  gauze  after  curetting  is  not  a 
safe  procedure;  it  has  caused  peritonitis. 

The  too  copious  use  of  corrosive-sub- 
limate solution  for  injection  has  caused 
death.  If  the  cervix  will  not  yield  to 
simple  measures,  Hegar's,  Ellinger's,  or 
Barnes's  dilator  may  be  used. 

New  method  of  treating  incomplete 
abortion:  With  Bozeman's  intra-uterine 
douche,  a  hot  creolin  solution  is  allowed 
to  flow,  always  watching  to  see  that  the 
return-cuiTent  remains  free.  All  loose 
clots  and  debris  are  removed  by  the  dull 
curette.  The  cavity  is  again  washed, 
until  nothing  remains  but  the  firm  de- 
cidual tissue  (which  clings  to  the  uterine 
wall)  and  the  creolin  solution  returns 
white.  Finally  the  uterus  is  packed 
from  the  fundus  to  the  external  os  with 
iodoform  gauze.  The  first  gauze  is  with- 
drawn, thereby  wiping  out  the  cavity, 
and  a  second  piece  is  firmly  placed  so  as 
to  stop  all  haemorrhage.  No  opiate  is 
allowed. 

As  a  result  of  this  procedure  the  inert 
uterus  is  stimulated  to  contract.  The 
blood,  unable  to  escape,  distends  the 
cavity  and  flows  in  between  the  decidua 
and  the  uterine  wall,  dislodging  the 
former.  Finally,  the  internal  os  dilates, 
the  gauze  is  expelled,  and  all  the  uterine 
cavity  with  it.  Another  creolin  intra- 
uterine douche  is  then  given,  and,  if  en- 
dometritis exist,  the  gentle  use  of  the 
sharp  curette   and   a   gauze   drain   com- 


plete the  work.  Contraction  and  invo- 
lution of  the  uterus  go  on  rapidly.  Three 
illustrative  cases.  Anna  M.  Stuart  (N. 
Y.  Med.  Jour.,  Sept.  6,  '96). 

In  curetting  after  incomplete  abortion 
tliree  following  points  insisted  on:  1.  Be- 
fore introducing  the  curette  a  sound 
should  be  used  and  the  length  it  pene- 
trates marked  on  curette.  2.  A  specu 
lum  should  always  be  used.  3.  Iodoform 
(or,  preferably,  xeroform)  gauze  should 
be  introduced  into  the  uterine  cavity 
after  curetting  in  haemorrhage,  or  the 
gauze  should  be  packed  well  in  to  excite 
uterine  contraction  and  left  there  for 
twenty-four  hours;  in  infection  it  is  in- 
ti'odueed  loosely  to  act  as  a  drain  into 
vagina,  into  which  a  plug  of  cotton- 
wool is  placed  to  absorb  discharge. 
Beuttner  (Rev.  Med.  de  la  Suisse  Rom., 
Jan.  20,  '98). 

The  following  procedure  recommended 
in  incomplete  abortion:  Under  chloro- 
form cervical  canal  is  dilated  with,  first, 
index  finger  and  then  middle  finger. 
Uterus  is  fixed  with  hand  acting  through 
abdominal  wall.  Then,  with  two  fingers 
or  one,  interior  of  uterus  is  thoroughly 
scraped.  To  evacuate  uterus  it  is  some- 
times sufficient  to  make  traction  on  pla- 
cental fragments  \'\ith  fingers  or  with 
one  finger  hooked.  Usually  it  is  neces- 
sary to  employ  uterine  expression,  done 
by  placing  two  fingers  in  posterior  vagi- 
nal fornix  and  pressing  them  forward, 
while  with  other  hand  placed  on  hypo- 
gastriura  pressure  is  made  on  anterior 
fundus  uteri.  Uterine  cavity  is  then 
washed  out,  and  mixture  of  glycerin  and 
creasote  applied.  Only  when  there  is  any 
haemorrhage  and  the  uterus  docs  not  re- 
tract properly  it  is  necessary  to  plug 
utero-vaginal  canal  with  iodcform  gauze. 
P.  Budin  (Progres  Med.,  Sept.  17,  '98). 

Treatment  of  abortion  based  upon  100 
cases  met  with  in  four  years.  Vaginal 
plug  usually  quite  useless.  If  removal 
of  the  ovum  is  indicated,  the  manual 
method  is  always  preferable.  Expression 
fatigues  the  patient  very  little,  and  is 
indicated  when  the  os  has  a  diameter  of 
about  four  centimetres,  and  when  the 
ovum  is,  in  great  part,  detached  and  in 
the  cervical  canal.  In  15  cases  this  plan 
was  followed,  and  in  12  the  ovum  was 


64 


ABORTION.     TREATMENT. 


thus  deliveredj  but  in  3  only  pieces  came 
away,  and  the  rest  had  to  be  removed  by 
the  finger.    If  expression  fail,  two  fingers 
are  to  be  introduced  into  the  uterus,  and 
the  ovum  or  parts  of  it  at  once  taken 
away.      In    abortion,   just    as   in    labor, 
everything  should  be  removed  at  once. 
The  finger  is  generally  to  be  preferred  to 
the   curette.     The   use    of   all   kinds   of 
ovum   forceps    condemned.      Ninety-nine 
women  recovered  fully.     Drejer   (Norsk 
Mag.  for  Laegevidensk.,  No.  3,  Mar.,  '99) . 
Expectant  treatment,  antisepsis  being 
the  only  measure  resorted  to,  is  preferred 
by   some   (Varnier  and   Pinard),   active 
procedures   being   only   resorted   to    in 
cases  of  serious  hjemorrhage  or  infection. 
Study  of  4333  cases  in  Tauffer's  clinic 
tending    to    demonstrate    that   even    re- 
tained   membranes    should    only    be    re- 
moved    when     decided     indications     are 
present.     Velits    (Int.  klin.  Rund.,  Mar. 
8,  '91). 
In  cases  of  retention  of  the  placenta 
after  abortion  the  practice  of  Tarnier  is 
as    follows:     1.    Antiseptic    preliminary 
injections    either    of    permanganate    of 
potash,    1   to   2000,   or  of   carbolic-acid 
water,  20  to  1000,  with  iodoform  or  salol 
dressings  to  the  vulva.    2.  In  case  there 
is  danger  of  infection  through  putrefac- 
tion of  the  placenta,  recourse  should  be 
had  to  digital  and  antiseptic  curettage 
after  dilatation.    3.  When  the  physician 
is   called   after   septicasmia   has   become 
generalized,  or  when  the  symptoms  of 
infection   are  very  pronounced,   it  be- 
comes necessary,  considering  the  immi- 
nence of  the  danger,  to  resort  to  curet- 
tage of  the  uterine  cavity,  using,  at  the 
same   time,    all    antiseptic    precautions. 
Quinine,    in    large    doses,    has    recently 
been  recommended. 

The  expectant  treatment  of  abortion 
is  to  be  preferred.  Packing  of  the  uterus 
and  vagina  recommended.  Of  292  cases 
observed  only  1  ended  fatally.  This  pa- 
tient was  already  infected  and  suffer- 
ing from  high  fever.  Curetting  and  local 
treatment  wei-e  unsuccessful. 


It  is  best  to  leave,  as  long  as  possible, 
the  expulsion  of  the  ovum  to  the  natural 
forces,  which  in  many  cases  of  abortion 
are  better  able  to  do  it  than  our  hands 
and  instruments.  When  some  special 
danger  exists  for  the  mother,  however, 
or  when  the  termination  of  the  abor- 
tion may  easily  be  accomplished,  inter- 
ference is  permissible. 

The  fear  of  packing,  which  until  re- 
cently was  prevalent,  has  disappeared, 
for,  with  due  precaution,  it  is  Avithout 
danger.  There  is  not  so  much  danger 
of  infection  with  it  as  with  manual 
and  instrumental  procedures.  P.  Miiller 
(Volkmann's  Samml.  Klin.  Vort.,  No. 
153,  Apr.,  '96). 

Case  of  sevei'e  post-partum  infection  in 
which,  notwithstanding  active  measures, 
the  patient  seemed  to  be  becoming  mori- 
bund. Twenty  ounces  of  sterilized  saline 
solution  injected  into  the  cellular  tissue 
at  first.  Improvement  of  the  symptoms 
followed  at  once.  The  injections  were 
continued  twice  daily  for  six  days.  Diu- 
resis and  a  fall  in  the  pulse-rate  were 
marked  throughout,  the  intestinal  irri- 
tation stopped,  and  the  temperatui'e  be- 
came normal.  The  patient  made  a  per- 
fect recovery.  Ostermayer  (Centralb.  f. 
Gynak.,  Mar.  12,  '99). 

Electricity  may  be  used  as  a  substitute 
for  the  curette  in  incomplete  abortion. 
For  the  immediate  removal  of  retained 
secundines  the  faradic  current  is  em- 
ployed, but,  for  the  removal  of  these 
after  retention  for  some  time,  the  gal- 
vanic is  preferable. 

Case  in  which  the  galvanic  current 
was  used  very  successfully,  the  strength 
being  60  milliamperes,  and  the  appli- 
cation continued  for  eight  minutes  and 
repeated  three  times.  The  positive  pole 
was  introduced  into  the  uterus,  the  selec- 
tion being  made  because  of  the  local 
effect,  since  this  pole  promotes  coagula- 
tion, and  is  haemostatic:  a  fourth  reason 
is  added  as  probable,  but  not  proved, — 
its  antiseptic  powers.  H.  D.  Fry  (Amer. 
Jour,  of  Obst.,  vol.  xxi,  p.  593). 

Injections  of  cold  water  successfully 
used  in  retention  of  the  placenta,  in  a 
woman  who  had  expelled  a  foetus  of  six 


ABORTION.     HABITUAL. 


55 


months.  Immediately  after  the  lavage 
the  uterus  contracted  and  the  placenta 
was  also  expelled.  John  Morton  (Indian 
Med.  Record,  Dec,  '91). 

Two  hundred  and  seven  cases  per- 
sonally treated  vpith  curette.  Sequelte 
were  met  with  in  only  34.4  per  cent, 
compared  with  92.4  in  those  in  which 
it  was  not  employed.  In  the  former, 
the  menses  were  regularly  re-established 
in  60  per  cent.,  pregnancy  to  term 
supervened  in  53  per  cent.,  abortion  re- 
curred in  only  13  per  cent.,  and  sterility 
prevailed  in  32.3  per  cent.  "^^Iien  the 
curette  was  not  used  and  fingers  were, 
regular  menstruation  in  39.4  per  cent., 
pregnancy  to  term  also  in  39.4,  repeated 
abortion  in  47.3,  and  sterility  in  25.1. 
The  cases  were  all  treated  upon  the 
same  general  principles,  and  the  curette 
was  only  employed  in  the  presence  of 
the  strongest  indications.  Schaeflfer 
(Deutsche  Praxis,  Nos.  1-3  and  5-8, 
1901). 

Streptococcic  serum  in  the  septicaemia 
of  abortion  has  been  used  with  apparent 
success. 

Exhaustion  from  Hemorrhage. — 
This  condition  maj'  be  treated  by  rectal 
injections  of  1  or  2  quarts  of  cool  saline 
solution,  or  careful  injection  of  hot 
(120°  F.)  saline  solution  into  the  femoral 
artery  (middle  of  Poupart's  ligament), 
using  a  larg€  hypodermic  needle  con- 
nected with  a  Davidson  syringe.  Sub- 
cutaneous and  rectal  saline  injections 
may  be  given  simultaneously,  if  need  be. 
Hypodermic  injections  of  Veo  grain  of 
strychnine  enhance  the  action  of  injec- 
tions. 

Habitual  Abortion.  —  Etiology.  — • 
Habitual  abortion  may  be  due  to  either 
constitutional  or  local  causes.  Of  the 
former  the  principal  are  syphilis,  lead 
poisoning,  tobacco  poisoning,  and  heart 
disease. 

The  local  causes  are  divided  into  four 
groups:  Malformations  of  the  uterus, 
displacements  of  the  uterus,  active  con- 
gestion of  the  uterus  and  especially  of 


the  cervix,  and  diseases  of  the  cervix  or 
body  of  the  uterus. 

Malformations.  —  In  these  cases  the 
uterus  has  preserved  some  of  the  char- 
acters of  the  infantile  uterus,  the  body 
being  disproportionately  small  or  the 
cervix  disproportionately  large.  Disten- 
sion of  the  uterus  by  the  growing  ovum 
causes  severe  attacks  of  uterine  colic  and 
sympathetic  disturbances,  which  com- 
mence during  the  second  month,  and 
usually  lead  to  abortion  about  the  third 
or  fourth  month.  These  cases  are  not 
common,  because  fecundation  is  rare  in 
the  malformed  uterus. 

Displacements. — Flexions  are  of  more 
importance  in  this  connection  than 
either  versions  or  prolapse.  In  ante-  or 
retro-  flexions  there  is  a  thickening  of 
the  uterine  tissue  at  the  angle  of  flexion, 
which  interferes  seriously  with  the  prog- 
ress of  pregnane}',  and  leads  to  repeated 
abortion  at  the  third  or  fourth  month. 

Congestions. — In  the  case  of  women 
who  habitually  lose  freely  at  the  monthly 
periods  it  is  not  uncommon  to  find  that 
during  pregnancy  they  have  a  periodic 
loss  of  blood,  accompanied  by  pain,  es- 
pecially during  the  latter  months.  In 
plethoric  women  these  haemorrhages 
during  pregnancy  are  beneficial,  and 
should  not  be  arrested. 

Diseases  of  the  Uterus. — Endometritis, 
new  growths  of  the  body  of  the  uterus, 
and  extensive  erosion  of  the  cervix  usu- 
ally lead  to  abortion.     (Charpentier.) 

Treatment.  —  The  causes  should  be 
sought  after  and  any  existing  affection 
removed,  if  possible.  Syphilis  especially 
requires  prolonged  and  curative  treat- 
ment. In  congestion  of  the  uterus 
Carpentier  recommends  wet  cupping  of 
the  loins  to  relieve  the  engorgement, 
and  thus  enable  the  uterus  to  retain  the 
ovum.  Any  special  irritability  of  the 
genital  organs  that  may  exist  should  be 


56 


ABORTION.     HABITUAL.     TREATMENT. 


treated  by  rest  in  bed  for  some  days  at 
the  menstrual  period  during  pregnancy. 
Viburnum  prunifolium,  ^/j  to  1 
drachm  of  the  iluid  extract  twice  daily, 
or  asafoetida,  1  grain  in  pill  three  times 
daily,  as  soon  as  pregnancy  is  suspected, 
and  gradually  increased,  are  frequently 
recommended.  Chlorate  of  potassium, 
15  to  30  grains  daily,  is  valuable  in  this 
connection,  but  is  more  likely  to  disturb 
the  stomach. 

A  large  number  of  drugs  possess  more 
or  less  marked  powers  as  abortifacients 
and  hence  should  be  avoided  during 
pregnancy.  Quinine,  cantharides,  pilo- 
carpine, strychnine,  erigeron,  elaterium, 
jalap,  podophyllin,  aloes,  senna,  scam- 
mony,  and  violent  purgatives  in  general, 
especially  those  likely  to  cause  engorge- 
ment of  the  hsemorrhoidal  vessels,  are 
the  most  pernicious  agents  in  this  par- 
ticiilar  that  are  in  general  use  as  reme- 
dies for  other  conditions. 

Although  quinine  appears  to  have  but 
little  oxytocic  action  in  some,  in  others 
it  excites  uterine  contractions,  especially 
in  delicate,  nervous,  and  anaemic  women; 
it  should  not  be  given  in  large  doses  un- 
less with  some  narcotic  that  will  act  as 
sedative  upon  the  uterus.     (Coromilas.) 
To  replace  quinine,  when  indicated  for 
malaria,  phenocoll,  which,  while  efficient 
for    malaria,    has    no    action     on    the 
uterus ;  22  grains  divided  in  four  cachets 
given  five,  four,  three,  and  two   hours 
before  febrile  paroxysm.     Titone    (Brit. 
Med.  Jour.,  Mar.  23,  '9.5). 

Cases  of  so-called  habitual  abortion, 
which  so  commonly  depends  on  a  dis- 
eased state  of  the  endometrium,  may  be 
overcome  by  a  two  minutes'  steaming  at 
212°  F.,  followed,  for  six  or  eight  days, 
with  applications  of  tincture  of  iodine. 
Results  in  ten  cases:  In  five  the  fever 
disappeared  speedily  by  crisis,  in  two 
lysis  occurred,  and  in  three  there  was  no 
notable  fever  to  begin  with.  The  occur- 
rence of  lysis  indicates  infection  of  a 
moderate  grade.    In  almost  all  cases  the 


odor  ceased  at  once  or  became  so  slight 
as  to  be  hardly  noticeable.  Pincus  (N. 
Y.  Med.  Jour.,  Mar.  20,  '97). 

In  cases  in  which  women  who  are 
usually  regular  pass  over  a  period,  as 
well  as  in  habitual  abortion,  exhibition 
of  5  to  8  grains  of  aeetanilid,  repeated 
in  one,  two,  or  four  hours  as  necessary, 
advocated.  In  cases  of  ovarian  irrita- 
tion, where  there  seems  to  be  tendency 
to  separation  of  ovum  at  what  would 
have  been  a  menstrual  period,  more  or 
less  regular  use  of  viburnum  prunifolium 
and  potassium  bromide,  with  aeetanilid 
at  time  of  each  periodic  disturbance, 
recommended.  In  emergency  cases  aee- 
tanilid 10  to  15  grains,  repeated  at  short 
intervals,  should  be  given,  but  in  every 
instance  individual  susceptibility  should 
be  considered.  Harnsberger  (Jour. 
Amer.  Med.  Assoc,  Oct.  22,  '98). 

Twenty-one  cases  of  abortion  and 
premature  labor,  with  death  of  the  em- 
bryo or  foetus.  These  were  treated  by 
prolonged  rest  in  bed,  and  by  the  ad- 
ministration of  iodide  of  potassium  and 
iron  throughout  the  entire  pregnancy. 
The  avithor's  cases  may  be  divided  into 
three  classes:  one,  syphilitic,  in  which 
the  sj'philis  was  old  or  hereditary;  the 
second  class,  in  which  the  kidneys  were 
very  deficient  in  action  and  the  patient 
was  threatened  with  nephritis;  and  the 
third  class,  in  which  the  patient  was 
constantly  absorbing  necrotic  material 
from  a  chronic  endometritis.  He  be- 
lieves that  the  treatment  acts  by  pre- 
venting the  rupture  of  vessels  in  the 
placenta.  Stress  is  also  laid  upon  the 
chronic  anaemia  present  in  these  cases, 
for  which  the  author  uses  iron.  Lomer 
(Zeits.  f.  Geb.  u.  Gj'nilk.,  Bd.  xlvi,  H.  2, 
1901). 

Potassium  chlorate  recommended  in 
habitual  abortion.  As  soon  as  the  pa- 
tient i.s  pregnant  3-grain  doses  of  potas- 
sium chlorate  are  given.  This  is  con- 
tinued during  the  entire  period  of  gesta- 
tion, decreasing  the  daily  dose  of  the 
drug  in  the  last  weeks  to  2'/=  grains. 
No  untoward  effect  has  been  observed, 
either  on  the  mother  or  the  child,  from 
this  treatment.  The  pregnancy  was 
brought  to  normal  completion  in  a  num- 
ber of  women  who  previously  had  noth- 


ABORTION.    MISSED. 


57 


ing  but  miscarriages.  S.  Remy  (Semaine 
Medicale,  xxii,  No.  39,  1902). 
Missed  Aboetion.  —  The  embryo 
sometimes  dies  as  a  result  of  the  con- 
ditions giving  rise  to  abortion,  and  re- 
mains in  the  iiterine  cavity, — the  so- 
called  "missed  abortion."  The  active 
symptoms  of  miscarriage  may  be  pres- 
ent; or  the  patient  may  only  ascertain 
by  the  cessation  of  all  foetal  motion  that 
it  is  no  longer  living.  The  foetus  may 
entirely  disappear,  or  become  trans- 
formed into  a  shrunken  remnant.  They 
are  most  frequently  expelled  within  six 
months,  but  sometimes  remain  in  the 
uterus  as  long  as  eleven  months.  The 
usual  symptoms  of  premature  delivery 
are  gone  through.  In  its  altered  con- 
dition, the  product  is  variously  termed 
"fleshy  mole,"  "blighted  ovum,"  or 
"apoplectic  ovum."  The  occurrence  of 
this  complication  is  comparatively  rare. 
It  may  repeatedly  occur  in  the  same 
woman. 

Case  of  missed  abortion  in  which  the 
embryo  perished  during  the  second 
month  of  pregnancy,  and  was  retained 
until  the  tenth  month.  I.  Kobro  (Norsli 
Mag.  f.  Lag.,  4  R.,  X  12,  S.  1110.  '9.5). 

The  first  factor  is  the  death  of  the 
foetus;  this  is  followed  by  shrinking  of 
the  chorionic  sac  and  blood-extravasa- 
tion among  the  villi.  As  a  result,  nu- 
merous small,  rounded  protrusions  are  to 
be  seen  when  the  interior  of  the  sac  is 
examined, — the  so-called  "subehorionic 
hffimatomata,"  "tuberous  subehorionic 
hsematomata,"  or  the  "tuberculous  ova" 
of  Granville.  They  are  considered  by 
some  observers  as  malignant. 

When  the  fcetal  circulation  ceases,  the 
ve.ssels  of  the  placenta  are  rapidly  ob- 
literated. The  foetal  epithelium  covering 
the  chorion  and  its  villi  degenerate,  and 
the  maternal  blood  between  the  villi 
forms  clots,  which  are  altered  into  dense 
laminated  fibrin.  The  decidual  cells  then 
multiply    and    invade    the    fibrin,    which 


they  gradually  replace,  filling  the  inter- 
villous space  with  layers  and  bands  of 
decidual  tissue.  At  the  same  time  they 
disintegrate  the  foetal  epithelium,  which 
comes  to  be  represented  by  scattered 
heaps  and  row.s  of  nuclei,  and  finally  dis- 
appears. The  amnion  remains  almost 
unaltered,  but  adheres  closely  to  the 
chorion,  and  the  united  membranes  are 
thrown  into  folds  and  convolutions,  cov- 
ering the  rounded  lobes  of  altered  pla- 
cental tissue.  The  foetal  portion  of  the 
placenta  does  not  grow  after  the  death 
of  the  foetus,  though  the  maternal  por- 
tion containing  the  decidual  cells  re- 
mains active.  It  is  therefore  improbable 
that  malignant  new  growths  can  arise 
from  foetal  placental  elements.  W.  E. 
Fothergill  (Brit.  Med.  Jour.,  Mar.  20, 
'97). 

The  fleshy  mole  is  undoubtedly  a  form 
of  the  process  known  as  "abortion,"  but 
the  obstetrician  should  remember  that 
the  pathological  changes  which  produce 
it  may  occur  at  very  diilerent  stages  of 
pregnancy.  The  precise  time  at  which 
the  arrest  of  normal  pregnancy  occurs 
cannot  always  be  determined  by  exami- 
nation of  a  fleshy  mole.  Neumann 
(Monats.  f.  Geburt.  u.  Gyn.,  Feb.,  '97). 

In  tuberose  fleshy  mole  abortion  is  pro- 
duced in  the  following  manner:  There  is 
an  undue  blocking  of  the  serotinal  si- 
nuses in  the  large-celled  layer,  leading 
to  a  slow  engorgement  of  the  intervil- 
lous circulation.  This  will  bulge  out 
the  chorio-basal  septa,  and,  as  these 
tack  down  the  chorion  at  definite  points, 
the  amnion  and  chorion  will  bulge  up 
between.  This  produces  the  tuberose 
swellings.  The  embryo  dies  as  the  re- 
sult of  this  interference  with  the  cir- 
culation, and  its  death  is  "secondarj'." 
The  placenta  becomes  a  thrombosed 
mass  and  is  retained  a  certain  time 
before  expulsion.  The  primary  link  in 
the  chain  of  events  is  the  excessive 
clotting  in  the  serotinal  sinuses  from 
a  cause  as  yet  unknown.  D.  Berry  Hart 
(.Jour,  of  Obstet.  and  Gynsec.  Brit.  Em- 
pire,  May,   1902). 

The  first  symptom  is  usually  a  bloody 
discharge,  which  is  frequently  taken  for 
the  return  of  menstruation.    The  uterus 


58 


ABORTION.    INDUCED. 


is  found  to  be  enlarged  according,  of 
course,  to  the  size  of  the  foetus,  and 
the  internal  os  generally  permits  of  the 
introduction  of  a  finger-tip.  The  pres- 
ence of  the  ovum,  or  foetus,  may  there- 
fore be  ascertained  in  a  proportion  of 
cases,  but  when  this  is  impossible  the 
diagnosis  is  established  with  difficulty. 
The  discharges  generally  become  very 
foetid,  however,  and  suggest,  by  the  char- 
acter of  the  odor  emitted,  the  nature  of 
the  body  present. 

Treatment.  —  Bemoval  of  the  dead 
foetus  is  the  only  course  to  be  pursued. 
The  means  are  precisely  those  for  the 
removal  of  the  placenta  just  described, 
the  strictest  antisepsis  being  observed. 

Induced  Aboetion".  —  It  is  seldom 
necessary  to  induce  abortion  during  the 
earlier  months  of  pregnancy,  as  the  dis- 
orders occasionally  rendering  this  step 
obligatory  are  frequently  amenable  to 
other  measures.  The  most  important 
conditions  that  may  necessitate  this  step 
are  incoercible  vomiting,  heart  disease 
threatening  life,  and  serious  hydramnios. 

Many  drugs — such  as  saffron,  tansy, 
wormwood,  cinnamon,  horehound,  etc. 
— generally  considered  as  capable  of 
provoking  expulsion  of  the  foetus,  are 
practically  without  effect,  while  more 
powerful  agents — such  as  rue  {Ruta 
graveoUns),  savin,  red  cedar.  Arbor  vitce, 
and  yew — are  only  active  when  giving 
rise  simultaneously  to  dangerous  general 
symptoms.  In  women  predisposed  to 
abortion,  however,  all  these  drugs,  be- 
sides others  previously  mentioned,  are 
capable  of  exciting  expulsive  contrac- 
tions of  the  uterus. 

The  means  for  the  purpose  are,  briefly, 
catheterization  of  the  uterus,  injections 
between  the  uttrus  and  ovum,  mechan- 
ical dilatation  of  the  cervix,  the  vaginal 
tampon  or  douche,  and  electricity. 

It  is  important  to  bear  in  mind,  in 


this  connection,  that  a  physician  should 
never  perform  abortion  without  one  or 
more  consultants. 

A  new  method  of  producing  abortion: 
A  curved  silver  catheter,  2  millimetres 
in  diameter,  is  passed  to  the  fundus 
uteri.  A  syringe,  with  a  capacity  of 
about  4  grammes,  is  attached  to  the 
catheter,  and  by  it  3  grammes  of  tinct- 
ure of  iodine  are  injected  into  the 
uterine  cavity.  The  catheter  is  now 
removed,  and  a  tampon  placed  against 
the  cervix  to  prevent  the  iodine  from 
coming  in  contact  with  the  vagina. 
This  method  is  uniformly  successful  and 
quite  free  from  danger.  The  abortion 
occurs  within  two  or  three  days.  The 
iodine  penetrates  and  destroys  the  em- 
bryo, while  its  antiseptic  properties  are 
a  safeguard  against  sepsis.  Oelschliiger 
(Edinburgh  Med.  .Jour.;  from  Centralb. 
f.  Gynilk.,  No.  27,  1901). 

The  electric  current  is  a  safe  means 
when  artificial  abortion  is  necessary. 
The  patient  is  placed  on  a  table  or 
gynfecological  chair,  the  external  geni- 
tals and  the  vagina  are  washed  with  a 
solution  of  formalin  or  lysol  and  soap, 
the  cervix  exposed  by  a  speculum,  and 
the  canal  cleansed  by  means  of  pledgets 
of  cotton  saturated  in  a  2-per-cent. 
solution  of  lysol.  Apostoli's  bipolar 
electrode  is  then  introduced  in  such  a 
manner  that  the  platinum  end  of  the 
second  attachment  is  seen  around  the 
external  os.  A  constant  current  is  ap- 
plied and  gradually  increased  from  50 
to  73  and  even  100  milliamperes,  for 
■  fifteen  minutes.  At  the  end  of  this 
time  the  electrode  is  removed  and  the 
cervix  and  vaginal  portion  of  the  uterus 
swabbed  with  a  2-per-eent.  solution  of 
lysol.  Three  applications  are  usually 
sviflSeient  to  insure  success.  M.  M. 
Mironoff  (Phila.  Med.  Jour.;  from  Jour. 
Akouscherstwa  i  Zshenskick  Boleznei, 
No.  12,  1901). 

Criminal  Abortion. — In  all  civilized 
countries  most  severe  punishment  is 
inflicted  upon  criminal  abortionists;  in 
most  of  them  the  penalties  are  increased 
if  the  crime  is  committed  by  professional 
persons,  such  as  medical  men,  midwives, 


ABORTION.     INDUCED. 


59 


and  druggists.  Notwithstanding  this, 
criminal  abortion  is  extremely  frequent, 
principally  in  large  cities. 

It  is  generally  between  the  second  and 
fifth  month  of  pregnancy  that  abortion 
is  artificially  produced. 

Criminal  abortion  is  performed  by 
means  of  drugs  and  by  local  and  sur- 
gical intervention.  A  large  number  of 
drugs  were,  until  recently,  thought  to 
possess  active  ecbolic  properties,  but  a 
more  elaborate  study  of  the  question  has 
shown  that  no  drug  has  a  special  action 
upon  the  uterus  for  expelling  the  prod- 
uct of  conception. 

Criminal  abortion  is  sometimes 
brought  on  by  using  lead.  Four  cases 
in  whielr  it  was  definitely  determined 
that  lead  was  taken  for  this  purpose, 
and  in  which  a  diagnosis  was  made  by 
discovering  a  blue  line  on  the  gums. 
Fourteen  similar  instances  known  of, 
some  of  which  were  personally  seen, 
others  having  occurred  in  the  practices 
of  colleagues.  As  a  rule,  the  diagnosis 
in  these  cases  was  at  first  acute  gastri- 
tis, renal  colic,  tubal  inflammation,  and 
similar  conditions.  In  many  cases  the 
patients  misrepresented  matters  abso- 
lutely, and  there  was  not  the  least  sug- 
gestion in  their  story  of  the  actual  cause 
of  their  condition.  Schwarzwaeller 
(Berliner  klin.  Woeh.,  Feb.  18,  1901). 

The  only  fact  to  be  admitted  in  a 
medico-legal  point  of  view  is  that  some 
drugs  may  cause  abortion  in  predisposed 
women,  but  more  by  the  general  dis- 
turbance of  the  system  than  by  any  spe- 
cific action  on  the  womb.  The  strong 
cathartics  (scammony,  jalap,  etc.),  given 
in  large  doses,  may  be  classed  in  this 
category.  Caustic  acids  are  also  active 
in  the  same  sense. 

Examination  of   72   women   on   whom 

criminal    abortion    had   been   performed. 

In   1   case   death  resulted  from   nervous 

shock. 

In   5    other   cases,    during    or   shortly 

after  the   injection,   faintness,   dizziness, 

and   vomiting   occurred,   lasting  several 


hours  and  disappearing  without  leaving 
any  trace.  In  nine-tenths  of  the  cases 
there  was  no  special  disturbance.  Abor- 
tion usually  resulted  in  the  course  of  a 
day,  sometimes  in  six  or  eight  hours.  In 
only  4  of  5  cases  was  fever  present  or  the 
patients  obliged  to  remain  in  bed  for 
several  days.  In  25  cases,  however,  there 
Mas  evident  endometritis,  which  propor- 
tion would  show  some  relation  to  the 
operation.  It  was  strange  that  no  septic 
troubles  arose,  as  no  special  care  was 
taken  either  of  the  syringe  or  the  solu- 
tion used.  Vibert  (Jour,  de  M6d.,  Feb. 
26,  '93). 

Case  of  criminal  abortion  by  the  use 
of  a  tupelo  tent  in  which  the  latter  had 
been  forced  through  the  uterine  walls. 
The  tent  was  found  lying  transversely  in 
Douglas's  cul-de-sac.  Supravaginal  hys- 
terectomy performed,  on  account  of  the 
septic  condition  of  the  pelvic  cavity. 
The  perforation,  beginning  at  the  inter- 
nal OS,  extended  obliquely  upward  and 
the  tent  had  been  forced  through  the 
serous  coat  Just  below  the  left  horn  of 
the  uterus.  W.  Easterly  Ashton  (Med. 
Bull.,  July,  '97). 

Opinion  recorded  as  to  liability  of 
person  who  consents  to  have  abortion 
performed  upon  her:  The  judge,  when 
summing  up  in  the  Collins  trial,  decided 
that  "the  woman  who  submits  herself 
to  an  unlawful  operation  is  guilty  of 
felony  just  as  much  as  the  agent  she 
employs."  Editorial  (Ga.  Jour,  of  Med. 
and  Surg.,  Sept.,  '98). 

Death  may  ensue  without  the  produc- 
tion of  traumatism,  during  the  intra- 
uterine use  of  instruments,  probably 
through  the  intermediary  of  the  sympa- 
thetic system. 

Case  of  sudden  death  during  attempted 
abortion  while  introducing  the  nozzle  of 
a  syringe  into  the  os  uteii.  Judicial  in- 
quiry. No  uterine  abnormality  found, 
although  the  cervix  was  soft  and  patu- 
lous. Death  seemed  to  be  due  simply  to 
syncope  from  a  stimulus  arising  in  the 
uterus.  It  was  a  phenomenon  of  inhibi- 
tion. Syncope  has  been  observed  after 
passage  of  the  sound.  De  la  Touche 
(Sem.  GyniSc.,  June  23,  '96). 


60 


ABORTION. 


In  performing  an  autopsy  upon  a 
woman  who  is  supposed  to  have  at- 
tempted abortion  search  should  be  made 
for  the  embryo  or  pieces  of  it,  or  for  the 
placenta.  If  the  uterus  is  empty,  the 
thickness  of  its  walls  must  be  measured, 
and  the  insertion  of  the  placenta  sought, 
as  this  can  be  recognized  up  to  the  tenth 
day  after  the  expulsion  of  the  embryo. 
This  is  possible  even  later,  if  the  uterus 
is  kept  in  90-per-cent.  alcohol.  The  ex- 
amination of  the  ovaries  is  of  only  rel- 
ative importance,  as  no  positive  signs 
exist  there.  Stains  of  meconium,  if 
found,  will  prove  the  abortion.  If  an 
instrument  has  been  used  to  cause  abor- 
tion, traces  of  the  damage  done  by  it  will 
be  seen.  This  is  especially  true  when  the 
uterus  has  been  perforated.  Brouardel 
(Jour,  des  Praticiens,  .Jan.  12,  1901). 

Six  hundred  and  ninety-eight  cases  of 
abortion  witnessed,  supposed  to  be  spon- 
taneous. Four  of  the  women  died:  that 
is,  0.57  per  cent.  During  the  same 
period  forty-four  cases  of  criminal 
abortion  were  treated:  the  mortality 
was  56.8  per  cent.:  that  is,  only  nine- 
teen women  recovered.  In  the  presence 
of  a  complete  or  incomplete  abortion, 
due  unmistakably  to  mechanical  meas- 
ures, or  even  when  such  abortive  meas- 
ures are  suspected,  and  in  absence  of 
any  complication,  early  evacuation  fif 
the  uterus  is  required.  If  septic  acci- 
dents have  already  developed,  evacua- 
tion is  still  more  urgent,  and  general 
measures  are  also  indicated.  Maygrier 
{L'Obstetrique,'July  4,  1902). 

A.    LUTAUD, 

Paris. 


ABSCESS.  —  Lat.,  ahscessus,  from  ah- 
scedere,  to  depart. 

Definition. — A  collection  of  pus  in  an 
adventitious  cavity,  the  result  of  an 
acute,  circumscribed  inflammation  due 
to  infection  with  pus-forming  microbes. 

Varieties. — An  abscess  may  be  acute, 
or  ivarm,  when  due  to  pus-microbes  only: 
staphylococci,  streptococci,  and  others; 
chronic,  or  cold,  when  due  to  a  specific 
microbe,  especially  that  of  tuberculosis. 


Abscesses  have  been  classified  accord- 
ing to: — 

1.  Etiology. — Atheromatous,  embolic, 
fsecal  (stercoraceous),  lymphatic,  meta- 
static, miliary,  ossifluent,  puerperal,  pyse- 
mic;  residual  symptomatic,  or  congest- 
ive; tropical,  tubercular  (strumous,  or 
scrofulous),  etc. 

2.  Pathology. — Acute,  or  warm;  cana- 
licular; caseous;  chronic,  or  cold;  critical, 
difl:use,  gangrenous  (anthrax),  ligneous, 
perforating,  phlegmonous,  etc. 

3.  Location  [Organ  or  Tissue  In- 
volved).— Alveolar  (gum,  jaw,  teeth),  of 
antrum,  of  axilla,  bone  (subperiosteal), 
brain  (cerebral,  cerebellar),  bursal,  cor- 
neal (hypopyon),  deep,  dorsal,  follicular, 
hepatic,  of  hip-joint,  iliac,  ischio-rectal, 
lacunar,  lumbar,  mammary  (milk;  weid, 
or  weed;  breast),  marginal,  mediastinal, 
meningeal  (extradural,  subdural),  of 
middle  ear,  of  neck,  nephritic  and 
perinephritic,  of  nose,  of  palate,  palmar, 
of  pancreas,  pectoral  (empyema),  peri- 
typhlitic,  popliteal,  of  prostate,  psoas, 
rectal,  retropharyngeal,  of  skin  (furun- 
culosis),  of  scalp,  of  space  of  Eetzius 
(preperitoneal  cavity);  spinal,  or  verte- 
bral; of  spleen,  superficial,  thecal,  ure- 
thral and  periurethal,  vulvo-vaginal 
(Bartholinian),  etc.  All  the  above 
^•arieties  will  be  considered  under  their 
respective  anatomical  heads. 

Acute,  or  Warm. 

Symptoms, — An  abscess  may  either  be 
superficial  or  deep.  When  it  is  super- 
ficial the  local  symptoms  predominate; 
when  it  is  deep  the  general  symptoms 
are  generally  the  most  marked. 

The  pain,  due  to  compression  of  the 
nerves  by  the  disturbed  tissues,  varies 
in  degree  with  the  density  of  the  parts 
involved,  the  local  supply  of  sensitive 
nerves,  and  the  tension  produced  by  the 
inflammatory  products.  In  superficial 
abscess  the  pain  is  generally  localized  in 


ABSCESS.    ACUTE.     SYMPTOMS.    ETIOLOGY. 


61 


the  centre  of  the  swelling,  and  is  sharp 
and  lancinating;  in  deep  abscess  it  is 
more  diffuse  and  dull. 

Eedness  is  due  to  engorgement  of 
the  local  blood-supply,  and  the  swelling 
to  the  inordinate  distension  of  the  ves- 
sels and  the  secondary  escape  of  blood- 
plasma,  colorless  corpuscles,  etc.,  into 
surrounding  tissues.  It  may  become  very 
great  in  regions  such  as  the  lids,  the  lips, 
etc.,  in  which  the  cellular  tissue  is  lax. 
As  the  purulent  foci  run  together  and 
form  a  single  cavity,  the  centre  of  the 
tumefaction  becomes  soft,  and  darker 
in  color,  and  the  abscess  is  said  to  be 
"pointing." 

(Edematous  infiltration  in  superficial 
abscess  denotes  the  presence  of  pus;  in 
deep  abscess  subcellular  oedematous  in- 
filtration is  an  important  sign  of  deep 
suppuration. 

Local  heat,  throbbing,  and  tension  are 
mechanical  results  of  the  causes  of  tu- 
mefaction tending  to  decrease  as  the 
formation  of  pus  progresses. 

Plyperpyrexia  is  in  relation  with  the 
location  of  the  abscess,  the  ease  with 
which  the  pus-microbes  can  enter  the 
circulation,  and  the  amount  of  pus  and 
necrotic  tissues  present.  In  superficial 
abscess  there  is  but  little  rise  of  tempera- 
ture, but  in  deep  abscesses  it  sometimes 
reaches  104°  P.  (40°  C.)  at  the  time  the 
wall  of  granulation  tissue  is  established. 
A  remission  of  about  one  degree  each 
morning  usually  takes  place.  When  the 
pus  has  found  an  issue,  or  has  become 
completely  surrounded  by  the  limiting 
membrane,  the  intensity  of  the  fever  is 
usually  reduced. 

In  a  superficial  abscess,  if  a  chill  oc- 
cur, it  is  usually  very  slight,  and  appears 
between  the  fourth  and  the  eighth  day. 
It  indicates  the  formation  of  pus.  In  a 
deep  abscess  a  chill  generally  occurs,  last- 
ing from  a  few  moments  to  half  an  hour. 


Eluetuation  is  generally  obtained  when 
the  purulent  focus  has  been  formed.  A 
sharp  localized  pain,  on  pressure  over  the 
apex  of  the  swelling,  obtained  at  this 
time  supports  the  likelihood  that  pus  is 
present,  but  fluctuatipn  is  liafcle  to  be  a 
misleading  symptom. 

Interference  with  motion  or  the  normal 
functions  of  a  part  is  sometimes  produced 
through  the  proximity  of  the  abscess. 

Etiology. — Inflammation  due  to  trau- 
matisms and  lesions  of  all  kinds,  espe- 
cially the  introduction  of  foreign  bodies 
under  the  epidermis,  are  the  usual  causes 
of  abscess.  While  blows  do  not  appar- 
ently produce  superficial  lesions  in  the 
majority  of  cases,  the  fact  remains  that 
an  invisible  abrasion  may  be  present  and 
serve  as  a  channel  for  the  introduction  of 
the  pyogenic  organism.  The  cutaneous 
glands,  through  weakened  local  resist- 
ance, may  also  become  the  transmitting 
media.  Any  cause  removing  the  epithe- 
lial layer  of  the  mucous  membrane  may 
also  form  the  primary  etiological  factor 
of  an  abscess  in  the  membrane  or  in  the 
submucous  connective  tissue.  Abscesses 
also  arise  in  connection  with  the  various 
septic  fevers. 

Suppuration  can  occur  in  man  with- 
out the  presence  of  bacteria.  Both  in 
animals  and  in  man  suppuration  may 
be  due  to  the  irritation  of  chem- 
icals. Investigators  have  shown  that 
suppuration  is  only  a  certain  stage  of 
inflammation,  not  a  separate  qualita- 
tive form  of  inflammation.  The  serous 
formation  of  blebs  and  buUse  becomes 
purulent  without  the  presence  of  bac- 
teria. Karl  Kreibich  (Wiener  klin. 
Woch.,  June  13,  1901). 

Case  of  subcutaneous  abscesses  due 
to  the  gonococcus  in  a  child  2  years 
of  age.  The  little  patient  sufl'ered  from 
typhoid  fever,  and  a  few  days  after  ad- 
mission to  the  hospital  developed  an 
acute  anterior  urethritis,  which  was 
proven    to     be     gonorrhoeal    in    nature. 


62 


ABSCESS.     ACUTE.     PATHOLOGY.     DIFFERENTIAL  DIAGNOSIS. 


The  source  of  infection  could  not  be 
established.  Seven  and  ten  days  later, 
respectively,  areas  of  induration  ap- 
peared to  the  left  and  right  of  the  anus. 
Both  were  found  to  contain  pus  in  which 
gonococci  were  present.  Gershel  (Med. 
Record,  Feb.  7,  1903). 

Pathology. — While  several  varieties  of 
micro-organisms  are  found  in  the  pus 
of  an  acute  abscess,  staphylococci  and 
streptococci  are  by  far  those  most  fre- 
quently observed,  the  former  being  usu- 
ally found  in  circumscribed  abscess  and 
the  latter  in  diffuse  ones.  The  first  step 
in  the  process  is  increased  rapidity  of  the 
flow  of  blood  in  the  part,  the  vessels  be- 
coming engorged  and  dilated.  This  is 
succeeded  by  slowing  of  the  current  and 
passage  through  the  vascular  walls  and 
into  the  surrounding  tissues  of  colorless 
corpuscles  (leucocytes),  a  few  red  cor- 
puscles, and  blood-plasma,  the  latter  of 
which  become  coagulated  and  finally 
softened.  One  or  several  cavities  are 
thus  formed;  but,  if  the  cavities  are 
multiple,  the  barriers  usually  soften  and 
a  single  focus  is  established.  The  pus  is 
composed  of  the  corpuscles  which  perish 
in  the  cavity  thus  formed,  the  broken- 
down  remains  of  tissue,  and  the  plasma. 
At  a  distance  from  the  location  of  the 
abscess  the  circidation  is  normal,  but,  as 
the  diseased  area  is  approached,  the  slow- 
ing of  the  blood-current  becomes  gradu- 
ally more  evident,  until  a  zone  of  living 
leucocytes  is  met,  forming  a  protective 
barrier  around  the  abscess-cavity.  The 
surrounding  parts  also  become  permeated 
with  new  vessels,  and  a  zone  of  granula- 
tion tissue  (the  pyogenic  membrane  of 
older  writers)  is  formed.  The  spread  of 
the  suppuration  being  thus  checked,  the 
pus  is  forced  to  the  surface  because  it 
finds  the  least  resistance  in  that  direc- 
tion; but,  if  an  aponeurosis  or  fascia 
interfere,  it  burrows  until  an  exit  is 
found. 


The  role  of  the  white  corpuscles  (leu- 
cocytes) has  been  interpreted  in  various 
ways;  Cohnheim  considered  them  as  ele- 
ments of  repair;  others  have  attributed 
to  them  the  role  of  scavengers.  The 
prevailing  theory  at  present,  however,  is 
that  of  Metschnikoff,  who  considers  them 
able  to  attack  and  destroy  invading  or- 
ganisms. The  process  is  termed  by  him 
phagocytosis,  the  cells  being  called  pha- 
gocytes (^aj^6),to  eat,  and  ?£i;to$,  a  cell). 

The  dead  leucocytes  in  pus  must  be 
looked  upon  as  the  cells  that  have  been 
brought  up  rapidly  to  interfere  with  the 
spread  or  diffusion  of  the  products  of 
the  micro-organisms;  a  large  number  of 
these  cells  coming  in  contact  with  the 
poison  in  a  concentrated  form  may  suc- 
cumb to  its  action;  but  before  doing  so 
they  are  able  to  deal  with  a  certain  quan- 
tity of  the  poisonous  material,  breaking 
it  down  and  rendering  it  inert.  Other 
cells  are  constantly  being  brought  up  to 
assist  these,  until,  at  length,  the  bacteria 
are  completely  hemmed  in.  They  live 
for  a  short  time  on  the  dead  tissues;  but, 
being  localized  by  the  barrier  of  leuco- 
cytes, they  ultimately  die,  either  from 
inanition  or  because  they  are  poisoned 
by  their  own  products.  It  is  found  very 
frequently  on  opening  an  abscess  that 
no  organisms  can  be  seen,  those  that 
were  originally  present  appearing  to  haA'e 
undergone  degenerative  changes  and  to 
have  been  taken  up  by  the  phagocytes, 
or  devouring  cells.    (Sims  Woodhead.) 

Differential  Diagnosis.  —  Fluctuation 
onh'  indicating  the  presence  of  fluid,  the 
presence  of  this  sign  without  the  other 
symptoms  mentioned  should  inspire  great 
circumspection,  especially  if  surgical 
measures  are  to  be  resorted  to. 

Aneueism  is  the  most  dangerous  con- 
dition to  fear.  Its  less  acute  history,  and 
the  thrill  and  its-expansile  pulsation,  can 


ABSCESS.     ACUTE.     PROGNOSIS.     TREATMENT. 


63 


only  exist  in  close  proximity  to  a  large 
vessel. 

Certain  semisolid  growths  may  sim- 
ulate an  abscess.  When  the  possibility  of 
an  aneurism  has  been  eliminated,  a  fine 
trocar  or  exploring  needle,  if  carefully 
used,  will  determine  the  diagnosis. 

Prognosis.  —  This  depends  upon  the 
general  health  of  the  patient.  In  the 
robust  a  suppurative  process  usually 
reaches  the  stage  of  resolution  without 
giving  rise  to  complications.  In  individ- 
uals weakened  by  disease,  hereditary  or 
acquired,  an  abscess  may  be  protracted 
and  exhaustive,  and  diffusion  is  more 
likely  to  occur  if  resisting  tissues  inter- 
fere with  the  superficial  evacuation  of 
the  pus.  Deep  abscesses  are  especially 
prone  to  become  protracted  through  this 
cause,  the  resistance  of  muscular  apo- 
neuroses, etc.,  forcing  the  pus  into  the 
cellular  interstices.  Fistulous  tracts,  or 
large  suppurative  areas,  are  thus  created, 
and  the  patient  may  succumb  to  blood 
poisoning  or  asthenia. 

Treatment. — General  Measures. — Best 
and  elevation  of  the  afEected  region,  if 
possible;  salines,  if  purgation  is  neces- 
sary. Easily  assimilable  food,  but  not 
low  diet;  avoidance  of  stimulating  bev- 
erages, alcohol,  coffee,  etc. 

Internal  Remedies. — If  the  case  is  seen 
early  the  suppuration  can  sometimes  be 
arrested  by  the  use  of  one  of  the  follow- 
ing agents,  supplemented  by  one  of  the 
local  applications:  Tincture  of  aconite, 
1  to  3  drops  every  hour,  closely  watching 
the  patient's  pulse;  tincture  of  veratrum 
viride,  1  drop  every  hour  until  the  pidse 
becomes  slower,  the  skin  moist,  and 
slight  nausea  is  experienced.  Calcium 
sulphide  (sulphurated  lime),  Vio  grain 
every  hour;   or 

3^   Sulphate  of  quinine,  1  grain. 
Ext.  of  nux  vomica,  ^/^  grain. 


For  one  pill;  to  be  taken  every  three 
hours. 

External  Bemedies.  —  The  surface  is 
carefully  cleansed  with  antiseptic  soap 
and  sprayed  with  a  2-per-cent.  carbolic- 
acid  solution,  or  with  hydrogen  peroxide, 
every  two  hours,  the  atomizer  being  used 
for  ten  minutes  at  each  sitting.  (Ver- 
neuil.) 

Compresses  dipped  in  hot  1  to  4000 
corrosive-sublimate  solution  are  very 
effective. 

If  the  abscess  is  located  upon  an  ex- 
tremity, a  1  to  4000  corrosive-sublimate 
solution  may  be  employed  in  the  form 
of  a  bath  for  the  limb,  the  latter  being 
left  in  the  solution  several  hours  at  a 
time. 

A  solution  of  nitrate  of  silver  (30 
grains  to  the  ounce)  may  be  applied 
frequently  with  a  camel's-hair  pencil. 

Tincture  of  iodine  may  be  applied  in 
the  same  manner  every  three  hours. 

When  the  surface  becomes  very  tender, 
belladonna  ointment  may  be  rubbed  in 
every  two  hours. 

In  abscesses  characterized  by  very 
severe  pain  a  10-per-cent.  solution  of 
cocaine  may  be  introduced  by  cataphore- 
sis,  the  anode  sponge  of  a  galvanic  bat- 
tery being  applied  to  the  part.  The 
sittings  should  last  five  minutes,  and  be 
repeated  every  three  hours,  the  current 
not  exceeding  5  milliamperes.  During 
the  intervals  warm  fomentations — with 
borated,  camphorated,  or  pure  water — 
are  of  great  value. 

Pads  of  gauze  wrung  out  of  hot  borie- 
acid  solution  (an  ounce  to  a  quart  of 
water),  applied  as  hot  as  the  patient  can 
bear  them,  and  well  covered  with  oiled 
silk  to  keep  in  the  heat  and  moisture, 
are  the  best;  wherever  applicable,  as 
with  the  hands  or  feet,  the  inflamed  part 
should  preferably  be  submerged  every 
hour  for  a  period  of  five  to  ten  minutes 


64 


ABSCESS.    ACUTE.    TREATMENT. 


in  the  hot,  boric  solution  itself.  James 
Stuart  (N.  Y.  Med.  Jour.,  Jan.  16,  '97). 
Surgical  Measures.  — li  suppuration 
cannot  be  avoided,  the  abscess  should  be 
opened  as  soon  as  an  adequate  quantity 
of  pus  has  formed  to  constitute  an  ab- 
scess sufficient  in  size  to  be  recognized 
by  the  surgeon  as  such  (Senn),  or  as  soon 
as  the  presence  of  pus  has  been  deter- 
mined by  tlie  exploring  needle  or  syringe. 
If  a  local  anffisthetic  is  necessary,  one 
of  the  following  may  be  used:  Twenty 
drops  of  a  1-  to  5-per-cent.  solution  of 
cocaine  introduced  subcutaneously  near 
the  abscess;  ether  sprayed  over  the  seat 
of  the  abscess  until  local  numbness  is 
experienced;  chloride-of-methyl  or  chlo- 
ride-of-ethyl  vapor.  The  latter  is  espe- 
cially efficacious;  the  parts  turn  white 
when  ready, — generally  in  about  two 
minutes.  Seltzer  water  spurted  over  the 
surface  may  be  used  to  advantage  when 
none  of  the  other  agents  can  be  obtained. 
To  open  an  ordinary  abscess  a  single 
small  incision  suffices;  but,  if  it  is  large, 
several  small  incisions  should  be  made 
to  render  perfect  evacuation  of  its  con- 
tents possible  by  drainage.  If  the  ab- 
.scess  is  superficial,  the  skin  alone  should 
be  cut,  but  if  it  is  deep  seated  the  skin 
and  fascia  should  be  incised  and  the 
grooved  director,  or  the  points  of  a  pair 
of  forceps,  used  to  reach  the  pus,  the 
opening  being  kept  patent  with  forceps. 
The  cavity  is  then  thoroughly  emptied 
and  syringed  out  with  1  to  4000  corro- 
sive-sublimate solution  until  the  fluid 
comes  out  perfectly  clear.  Pressure  with 
the  fingers  is  to  be  avoided.  The  in- 
cision and  its  siTrroundings  are  then  care- 
fully washed  with  the  same  solution,  and 
an  aseptic  drainage-tube  inserted.  The 
wound  is  dusted  with  iodoform  or  der- 
matol,  and  an  antiseptic  dressing  is 
applied,  exerting  slight  pressure  with 
bandage.      If   the   abscess   is   deep,   the 


drainage-tube  should  be  shortened  daily; 
if  it  is  superficial,  the  drainage-tube  can 
be  withdrawn  the  second  or  third  day. 

Thirty-two  eases  of  abscess  treated  by 
the  Otis  method:  The  skin  about  the 
affected  area  is  scrubbed  with  green  soap 
and  washed  with  sulphuric  ether  and 
then  with  bichloride  (1  to  1000).  A 
narrow  bistoury  is  then  inserted  into  the 
abscess-cavity,  and  the  contents  gently, 
but  thoroughly,  squeezed  out;  the  cavity 
is  irrigated  with  bichloride  (1  to  1000) 
and  immediately  filled  to  moderate  dis- 
tension with  warm  iodoform  ointment 
(10-per-cent.  iodoform  and  vaselin),  care 
being  taken  not  to  use  a  sufficient  de- 
gree of  heat  to  liberate  free  iodine.  An 
ordinary  glass  gonorrhcEal  syringe  is 
used,  the  plunger  being  removed,  and  the 
barrel  warmed  in  the  flame  of  an  aleo- 
hol-lamp  and  filled  with  ointment  by 
means  of  a  spatula.  On  finishing  the 
injection,  at  the  instant  of  withdrawing 
the  syringe  from  the  wound,  a  compress 
wet  with  cold,  bichloride  solution  is 
applied,  which  instantly  solidifies  the 
ointment  at  the  orifice,  preventing  the 
escape  of  that  into  the  abscess-cavity. 
A  large  compress  of  sterilized  gauze  is 
then  applied  by  means  of  a  firm  spica. 
The  patient  is  told  to  return  in  four 
days,  when,  if  all  is  well,  the  dressing  is 
reapplied;  but,  if  any  evidence  of  inflam- 
matory action  is  found  the  wound  is 
thoroughly  irrigated  and  cleansed  and 
the  injection  repeated.  It  is  simple  and 
safe;  the  patient  is  not  prevented  from 
going  about.  It  leaves  no  scar.  Edwin 
M.  Hasbrouck  (N.  Y.  Med.  Jour.,  June 
13,  '96). 

To  postpone  active  measures  until  the 
last  moment  should  be  relegated  to  the 
past.  Best  to  incise  it.  Break  down  all 
the  divisions  between  the  loculi  with  the 
flngers,  then  rub  the  walls  gently  and 
thoroughly  with  gauze  until  the  last 
swab  shows  no  trace  of  pus  or  debris. 
When  dressing,  distension  of  the  cavity 
with  irrigating  fluid  should  be  avoided. 
Plugging    favors    the    accumulation    of 


ABSCESS.  COLD,  OR  TUBERCULOUS.  SYMPTOMS.  PATHOLOGY. 


65 


blood  or  serum.  In  many  eases  primary 
union  may  be  obtained  by  stitching  the 
abscess.  If  any  fluid  accumulates,  it 
should  be  allowed  to  escape  as  soon 
as  possible.  Pus  will  not  flow  upward. 
Neve  (Indian  Med.  Jour.,  Aug.  16,  '99). 
To  prevent  stitch  abscesses  cleanse 
the  skin  in  the  usual  way  with  soap 
and  water,  and  rub  into  the  skin  of 
the  operative  field  hydrated  lanolin- 
oleate  of  mercury  (20  per  cent.).  A 
piece  of  lint  smeared  with  the  ointment 
covers  the  skin  until  the  second  inunc- 
tion, twelve  hours  later;  the  lint  is  then 
reapplied  until  the  time  of  operation, 
when  the  superfluous  ointment  is  rubbed 
off  with  sterile  gauze.  A.  E.  Maylard 
(Annals   of   Surgery,   .Jan.,    1902). 

Cold,  or  Tuberculous. 

Symptoms.  —  These  abscesses  fre- 
quently attain  a  large  size,  and  last  for 
months  without  their  presence  being  de- 
tected. Besides  failing  general  health, 
the  symptoms  of  the  causative  trouble 
are  the  only  prominent  ones.  The  spine, 
the  hips,  the  genito-urinary  tract,  and 
the  lymphatic  glands  are  the  organs 
most  prone  to  tuberculous  disorders  giv- 
ing rise  to  cold  abscesses.  They  some- 
times appear  several  months  and  even 
years  after  the  beginning  of  the  primary 


No  pain  is  experienced,  as  a  rule;  cold 
abscesses  are  not  even  tender  to  the 
touch.  There  is  no  redness  until  the  ab- 
scess is  about  to  break,  the  focus  of  the 
liquid  mass  being  otherwise  too  deeply 
seated. 

Slight  hyperpyrexia  is  usually  present. 
There  is  no  local  heat;  hence  the  name 
"cold"  is  given  this  form  of  abscess  by 
the  Germans,  to  differentiate  it  from  the 
"warm"  abscess. 

The  above  symptoms  are  usually  fol- 
lowed by  the  sudden  appearance  of  a 
swelling.  Though  generally  soft,  it  may 
be  hard,  and  suggest  a  tumor  in  the 
vicinity  of  the  spinal  column  (Pott's  dis- 

1- 


ease),  above  or  below  Poupart's  ligament, 
after  burrowing  along  the  psoas  muscle 
(psoas  abscess),  on  the  inner  aspect  of  the 
thigh,  or  in  the  lumbar  region  (lumbar 
abscess),  etc.  In  the  neck  cold  abscesses 
are  usually  due  to  disease  of  the  neigh- 
boring cervical  lymphatic  glands.  The 
skin  either  remains  normal  or  gradually 
becomes  thinned  and  softened  until  an 
external  opening  is  formed. 

Fluctuation,  usually  detected  with 
ease,  is  sometimes  hidden  by  a  thick 
investing  layer  of  lymph,  which  gives 
the  mass  a  peculiar  tension,  suggesting 
a  lipoma  or  some  other  hard  growth. 
Aneurisms  sometimes  convey  the  sensa- 
tion produced  by  a  cold  abscess:  a  fact 
to  be  borne  in  mind  when  operative  pro- 
cedures are  under  consideration. 

Pathology.  —  A  cold  abscess  can  al- 
ways be  traced  to  a  specific  inflammatory 
process,  and  almost  invariably  to  one  of 
a  tubercular  nature.  Where  the  conflu- 
ent masses  in  the  centre  of  a  nodule 
begin  to  break  down,  there  is  formed  a 
collection  of  material  surrounded  by 
tuberculous  tissue.  This  material  be- 
comes infiltrated  with  leucocytes,  and 
thus  is  produced  a  cavity  containing 
fluid  fatty  material,  fragments  of  cells, 
and  leucocytes,  around  which  there  is 
granulation  tissue  filled  with  tubercles. 
In  this  way  a  tuberculous  abscess  is 
formed.  (Cheyne.)  It  seems  at  times 
to  be  quite  a  matter  of  accident  whether 
the  abscess  breaks  into  the  joint  or  finds 
its  way  by  a  more  circuitous  route  into 
the  surrounding  connective  tissue.  As 
the  tuberculous  masses  spread,  caseation 
takes  place  at  different  points  in  the 
wall,  and  the  masses  are  discharged  into 
the  cavity  of  the  abscess;  but  the  spread 
of  the  abscess  is  effected  generally  by 
what  is  termed  'Tiurrowing  of  pus." 
This  burrowing  occurs  in  various  direc- 
tions, and  large  collections  of  pus,  alto- 


66 


ABSCESS.     COLD.    DIAGNOSIS.    PROGNOSIS.    TREATMENT. 


getlier  out  of  proportion  to  the  original 
lesion,  are  formed,  and  are  known  as 
cold  abscesses.    (Warren.) 

What  has  been  called  a  chronic  ab- 
scess is  very  often  no  abscess  at  all.  In 
tubercular  processes  the  product  of 
tissue-proliferation  undergoes  coagula- 
tion-necrosis, and  disintegrates  into  a 
granular  mass,  which,  when  mixed  with 
a  sufficient  quantity  of  serum,  forms  an 
emulsion  that  microscopically  resembles 
pus,  but  under  the  microscope  shows 
none  of  the  histological  elements  which 
are  found  in  true  pus.  An  abscess  can 
only  be  called  such  if  it  contain  pus.  A 
true  chronic  abscess  can  originate  in  a 
tiibercular,  actinomycotic,  or  syphilitic 
lesion,  when  the  granulation  tissue  is 
secondarily  infected  by  the  localization 
of  pus-microbes,  which  convert  the  em- 
bryonal cells  into  pus-corpuscles.   (Senn.) 

Differential  Diagnosis. — The  concom- 
itant disorder  usually  makes  a  diagno- 
sis easy  in  a  case  of  cold  abscess;  but 
occasionally  the  swelling  is  the  only  in- 
dication of  ill  health,  and  it  is  important 
to  determine,  under  such  circumstances, 
the  nature  of  the  pus.  The  macroscop- 
ical  appearances  of  "laudable"  pus  and 
of  "sanious"  pus  are  frequently  so  simi- 
lar that  a  de  visu  diagnosis  is  not  Justi- 
fied. Bacteriological  examination  of  the 
contents  of  such  abscesses  will  show  con- 
clusively whether  they  are  true  pus-con- 
taining abscesses  or  whether  or  not  they 
are  pseudo-abscesses.  If  cultivations  are 
made  of  their  contents,  piis-microbes  will 
grow  upon  proper  nutrient  media  if  it 
be  a  true  abscess,  while,  from  the  con- 
tents of  a  pseudo-abscess  only  the  mi- 
crobes of  the  primary  infection  can  be 
cultivated.  The  information  obtained 
by  the  discovery  of  the  essential  cause 
can  be  confirmed  by  inoculation  experi- 
ments.    (Senn.) 

Prognosis.  —  The    walls    of   cold   ab- 


scesses are  usually  tense  and  tough,  and 
are  lined  with  cheesy  tuberculous  ma- 
terial. They  do  not  tend  to  collapse, 
as  is  the  case  with  acute  abscesses,  and 
for  that  reason  are  healed  with  difficulty. 
When,  however,  the  seat  of  the  original 
trouble  can  be  reached  and  successfully 
treated,  the  fluid  in  the  parts  of  the  ab- 
scess-tract is  absorbed,  and  the  caseous 
matter  undergoes  calcification.  This 
fortrinate  issue  of  the  case  is  seldom  met 
with,  however,  and  the  abscess  usually 
continues,  the  primary  etiological  factor 
acting  as  a  drain  for  the  diseased  area. 
The  prognosis,  therefore,  depends  upon 
the  result  obtained  in  the  treatment  of 
the  latter. 

Treatment. — It  is  a  well-known  clin- 
ical fact  that,  when  such  a  cold  or  tuber- 
ciilous  abscess  opens  spontaneously,  or  is- 
incised  in  a  careless  way,  profuse  sup- 
puration and  hectic  fever  follow,  with 
only  too  often  a  speedy  fatal  result  from 
septic  infection.  Unless  the  surround- 
ings of  the  patient  admit  of  carrying  out 
the  antiseptic  treatment  to  its  full  and 
perfect  extent,  a  chronic  abscess  should 
not  be  evacuated  by  incision.  It  should 
be  aspirated.  When  an  incision  can  be 
made,  it  should  be  free,  and  the  cavity 
should  be  thoroughly  curetted,  cleansed, 
disinfected,  and  iodoformized,  then  su- 
tured, drained,  and  treated  as  a  recent 
wound. 

On  general  principles,  necrosed  or  de- 
tached bone  should  be  looked  for  in  all 
cases.  Strict  antiseptic  precautions  are 
imperative  to  avoid  mixed  infection 
(bacilli  of  tuberculosis  and  pyogenic 
cocci).  Preliminary  precautions  should 
be  taken  to  meet  violent  hcemorrhage 
due  to  vascular  erosion. 

When  there  is  local  inflammation  and 
spontaneous  opening  of  the  abscess  is 
probable,  there  should  be  a  free  incision, 
a  thorough   scraping   of  its  walls  with 


ABSCESS. 


ABSINTHIUM. 


67 


Volkmann's  curette  to  transform  the 
suppurating  surfaces  into  bleeding  ones. 
The  cavity  is  then  cleansed  with  a  5- 
per-cent.  solution  of  carbolic  acid,  a 
long  drain  is  applied,  and  the  wound  is 
stitched  as  far  as  the  drain.  An  anti- 
septic dressing  is  then  applied.  (Volk- 
mann,  Trelat,  Pozzi.) 

After  opening  the  abscess  the  cavity 
may  be  washed  out  with  peroxide  of 
hydrogen  in  10-per-cent.  solution  or 
packed  with  iodoform  gauze.  Eemoval 
of  the  limiting  sac  is  then  performed 
by  decortication,  the  steps  being:  free 
incision,  the  sac  detached  with  finger  or 
spatula  and  removed,  and  the  cavity 
closed  immediately.     (Lannelongue.) 

Peroxide  of  hydrogen  is  a  prophylac- 
tic and  curative  medicament  in  the 
treatment  of  suppurative  skin  lesions 
so  common  in  infants.  A  twelve-volume 
solution  is  ample  as  a  skin-wash  twice 
daily.  This  rapidly  cures  superficial 
lesions.  Abscesses  must  obviously  be 
evacuated  before  the  peroxide  solution 
is  used.  Cochart  (Jour,  de  Med.  de 
Paris,  April  21,  1901). 

The  removal  of  the  limiting  sac  is 
facilitated  by  filling  the  wound  with 
paraffin;  the  mass  can  then  be  removed 
as  if  it  were  a  lipoma.    (Cazin.) 

A  psoas  abscess  should  be  opened  in 
the  loin  and  groin  when  possible.  In 
the  loin  the  incision  should  be  made 
through  the  external  and  internal  ob- 
lique, transversalis,  and  lumbar  fascia, 
along  the  outer  edge  of  the  erector  spinse 
to  the  edge  of  the  quadratiis  lumborum. 
The  latter  muscle  and  the  transversalis 
fascia  are  divided  on  a  level  with  the 
tip  of  the  second  or  third  lumbar  trans- 
verse process,  avoiding  the  lumbar  ar- 
teries. The  sheath  and  the  psoas  are 
then  perforated  with  the  finger  or  a 
trocar.  A  counter-opening  is  then  made 
below  Poupart's  ligament  to  form  a 
tunnel,  into  which  a  large-size  drainage- 


tube  is  inserted.  This  is  replaced,  later 
on,  by  a  tube  at  each  end  to  obtain  oblit- 
eration, beginning  from  the  centre  of 
the  canal.  If  one  incision  is  preferred 
the  loin  shoi^ld  be  selected. 

Aspiration  and  Injections. — AVhen  no 
local  inflammation  indicates  that  the 
abscess  is  soon  to  open,  the  fluid  may 
be  withdrawn  with  a  large  aspirator;  a 
5-per-cent.  solution  of  carbolic  acid  is 
injected  and  then  aspirated.  This  pro- 
cedure is  renewed  until  the  solution 
withdrawn  is  perfectly  clear.  A  Lister 
bandage  is  then  applied,  insiiring  slight 
pressure.  Five  days  later  the  treatment 
is  renewed.  About  five  sittings  are  re- 
quired.   (Boeckel.) 

Injection  fluids:  Iodoform,  1  part; 
ether,  5  parts;  distilled  water,  5  parts. 
Injection  not  to  be  renewed  while  iodo- 
form is  being  excreted  in  the  urine. 
(Mosetig-Moorhof,  Verneuil.) 

Less  painful  is  a  mixture  of  1  part  of 
iodoform  to  10  of  glycerin  (Billroth)  or 
of  olive-oil  (Brims). 

Intoxication  may  be  prevented  by 
sterilizing  the  iodoform  and  excipient 
(except  ether)  by  heating  at  212°  F. 
separately.    (Tillmann.) 

Boric  acid,  a  4-per-cent.  solution,  may 
be  used  as  above  (Menard),  or  naphthol 
and  camphor,  1  part  each.  About  thirty 
sittings  are  usually  required. 

The  lesion  being  a  tuberculous  one, 
the  general  system  should  be  treated  ac- 
cordingly. Nutritious  food,  including  a 
free  supply  of  milk  and  eggs,  pure  air, 
sunlight,  and  sea-air,  if  possible,  are  in- 
dicated, as  well  as  tonics  and  alteratives 
(codliver-oil  and  hypophosphites,  iodine, 
iodides,     arsenic,     quinine,     strychnine, 

etc.).  Q     guMNER    WiTHERSTINE, 

Philadelphia. 

ABSINTHIUM  (WORMWOOD)  .—Ab- 
sinthium   (the   Artemisa   absinthium   of 


68 


ABSINTHIUM. 


ACEXANILID. 


Linne)  is  a  fruit-bearing  plant  growing 
in  the  northern  latitudes  of  Europe, 
Asia,  and  Africa,  and  naturalized  in 
North  America.  It  grows  in  dry  ground 
and  is  often  found  along  roadsides.  The 
leaves  and  tops  are  utilized  in  pharmacy, 
and  contain  a  volatile  oil  and  other  con- 
stituents,— absinthol,  absinthin,  etc.  The 
preparations  usiially  employed  are  an 
infusion  and  the  powdered  leaves. 

Dose. — Volatile  oil,  1  to  2  minims;  in- 
fusion, 1  to  2  drachms;  powdered  leaves, 
20  to  40  grains. 

Physiological  Action.  —  Absinthium 
especially  affects  the  central  nervous 
system,  and  there  is  a  striking  resem- 
blance between  its  toxic  effects  and 
a  paroxysm  of  idiopathic  epilepsy, — 
namely,  twitching  of  the  muscles  of  the 
face  and  ears,  followed  by  clonic  and 
tetanic  spasms  of  the  muscles  of  the 
trunk  and  extremities,  with  salivation, 
cries,  involuntary  emission  of  urine,  and 
finally  a  period  of  unconsciousness. 

A  cordial — "absinthe" — is  extensively 
used  in  France  as  a  supposed  stomachic 
tonic  and  as  an  intoxicating  agent.  It 
surpasses  in  perniciousness  any  beverage 
known,  and  contributes  markedly  to  the 
deterioration  of  that  country's  popula- 
tion. 

Absinthe  Poisoning^.  —  As  already 
stated,  a  poisonous  dose  of  absinthe  gives 
rise  to  symptoms  simulating  an  attack 
of  epilepsy.  In  a  fatal  case  there  is 
abolishment  of  the  reflexes,  anuria,  and 
finally  arrest  of  respiration  and  of  car- 
diac action. 

Autopsy  of  case  in  which  death  had 
followed  the  ingestion  of  one  and  a  half 
pints  of  pure  absinthe.  The  liver  con- 
tained 0.21  of  1  per  cent,  of  aleoliol,  the 
blood  0.33  of  1  per  cent.,  and  the  brain 
0.44  of  1  per  cent.  The  epithelium  of 
the  stomach  and  that  of  tlie  kidneys 
were  desquamated.  The  mucous  mem- 
brane   of    the    stomach    and    the    renal 


blood-vessels  were  very  much  congested. 
The  stomach  presented  evidence  of  haem- 
orrhage in  the  larger  curvature.  Symp- 
toms attributed  more  especially  to  alco- 
hol, the  characteristic  effect  of  absinthe 
being  the  production  of  epileptiform 
coma.  Pauly  and  Bonne  (Gaz.  Hebd.  de 
Med.  et  de  Chir.,  May  13,  '97). 

Absinthe  is  not  only  an  epileptogenic 
poison,  but  also  a  stupefying  principle, 
which  would  add  its  action  to  that  of 
alcohol.  Lepine  (Gaz.  Hebd.  de  Med.  et 
de  Chir.,  May  13,  '97). 

Treatment  of  Poisoning.  —  Lavage  of 
the  stomach  should  at  once  be  resorted 
to  even  if  the  respiration,  the  cardiac 
action,  and  the  reflexes  are  apparently 
abolished. 

Therapeutics.  —  Absinthium  was  at 
one  time  used  as  antispasmodic,  febri- 
fuge, and  anthelmintic.  It  has  been 
generally  discarded,  however,  and  is  only 
considered  here  owing  to  its  present  role 
as  an  intoxicant. 

A.  C.  E.  MIXTURE.  See  Chloro- 
form. 

ACETANILID.— Acetanilid  (formerly 
known  under  the  name  of  antifebrin)  is 
a  white  crystalline  powder  obtained  by 
the  action  of  glacial  acetic  acid  upon  ani- 
line. It  is  odorless  and  gives  rise  to  a 
slight  burning  sensation  when  applied  to 
the  tongue.  It  is  but  slightly  soluble  in 
water,  but  completely  so  in  alcohol  and 
ether. 

Acetanilid  is  not  soluble,  but  is  readily 
suspended  in  syrupy  mixtures,  so  that  it 
can  be  combined  with  ammonia  in  any 
of  its  forms,  salicylic  acid,  nux  vomica, 
digitalis,  codeine,  ereasote,  potassium 
bromide,  or  indeed  almost  any  drug,  and 
a  prescription  obtained  that  can  be  much 
more  accurately  adapted  to  the  case  in 
hand  than  any  of  the  ready-made  com- 
binations. The  foundation  of  most  of  the 
coal-tar  product  combinations  is  acetani- 
lid, which  has  been  combined  with  bi- 
carbonate of  soda,  caffeine,  carbonate  of 


ACETAXILIIX     PHYSIOLOGICAL  ACTION. 


69 


ammonia,  etc.  The  combination  may  be 
chemical  or  mechanical,  it  matters  little 
which,  as  it  is  practically  broken  up  in 
the  body  into  the  acetanilid  radicals  and 
the  other  constituents.  It  is  much  more 
professional  and  scientific  to  write  for  the 
mixture  than  to  be  slaves  to  a  propri- 
etary combination.  Perhaps  the  most 
generally  useful  combination  of  acetan- 
ilid when  used  as  an  analgesic  is  the 
migraine  tablet.  This  is  the  equivalent 
of  several  of  the  most  widely-used  secret 
mixtures  that  are  sold  under  a  specific 
name.  It  consists  of  2  grains  of  acetan- 
ilid and  Va  grain  each  of  caffeine  citrate 
and  monobromate  of  camphor.  A  useful 
combination  that  can  be  prescribed  in 
capsule  is  acetanilid  and  quinine,  1  grain 
of  the  former  and  2  of  the  latter.  This 
makes  a  good  adjuvant  to  other  treat- 
ment in  eases  of  coryza.  In  rheumatic 
conditions,  and  those  in  which  there  is 
a  suspicion  of  intestinal  fermentation, 
acetanilid  and  salol  make  a  good  com- 
bination in  capsule.  For  disturbances  of 
circulation  and  neuroses  attending  the 
menopause,  2  grains  of  acetanilid  and  15 
grains  of  bromide  of  sodium  are  efficient 
when  combined  in  a  drachm  of  simple 
elixir.  When  repeated  sufficiently  often 
in  this  form.,  it  acts  as  an  efficient  hyp- 
notic. Acetanilid  is  a  useful  addition  to 
mixtures  for  the  relief  of  acute  indi- 
gestion attended  by  fiatulence  and  great 
distress  immediately  after  meals.  As  a 
substitute  for  iodoform  and  a  host  of 
antiseptic  dusting-powders,  acetanilid  has 
been  found  most  efficacious,  especially 
when  combined  with  boric  acid.  L.  F. 
Bishop  (Med.  News,  June  10,  '99). 

Dose  and  Physiological  Action. — When 
the  drug  was  first  placed  on  the  market, 
some  years  ago,  the  doses  administered 
were  excessive.  The  normal  dose  in  the 
healthy  adult  should  not  exceed  7  grains; 
4  grains  represent  the  proper  quantity  to 
be  administered  at  a  time. 

To  give  antifebrin  in  doses  of  5  and 
even  10  grains,  still  more  to  repeat  these 
after  a  short  interval,  is  a  highly-inju- 
dicious procedure.  Such  doses  are  ex- 
cessive, being  equivalent  to  about  25  and 
50  grains  of  antipyrine.     This  fact  of  its 


greater  strength  has  been  overlooked. 
Therapeutic  Committee,  British  Med. 
Assoc.  (Brit.  Med.  Jour.,  Jan.  13,  '94). 

For  children  the  dose  should  be  small, 
but  it  need  not  be  reduced  to  quite  the 
proportion  observed  for  most  drugs. 

The  action  of  acetanilid  upon  the 
heart  may  become  pronounced  unexpect- 
edly; its  effects  should  therefore  be 
closely  watched  in  children  and  weakly 
individuals. 

Case  of  collapse  occurring  after  a  dose 
of  3  grains.  The  same  dose  had  been 
given  eight  times  in  the  four  preceding 
days  without  evil  result;  possible  in- 
stance of  cumulative  action.  Kronecker 
(Ther.  Monats.,  Sept.,  '88). 

Fatal  case,  in  a  child,  from  the  admin- 
istration of  3  ■'/j  grains  every  two  hours 
during  the  day.  By  evening  the  child 
was  cyanosed  and  in  fatal  collapse. 
Editorial  (Provincial  Med.  Jour.,  Mar.  I, 
'89). 

Case  of  a  young  woman  who  took 
4-grain  doses  of  the  drug  at  frequent 
intervals,  until,  in  three  days,  48  grains 
had  been  taken.  On  the  third  day  the 
patient  suddenly  fell  from  her  chair,  un- 
conscious and  cyanosed. 

The  prolonged  use  of  acetanilid  is  cer- 
tainly not  without  danger.  This  may 
be  of  two  kinds:  1.  The  production  of 
marked  and  more  or  less  transient 
changes  in  blood-composition  from  its 
long  use.  2.  Cumulative  power  in  the 
drug.  Robert  Haley  (Weekly  Med.  Ee- 
view,  Nov.  9,  '89) . 

Acetanilid  used  in  1100  cases  of  dis- 
eases of  children,  in  600  of  which  a 
record  was  kept.  Conclusions  are:  (1) 
with  due  care  it  is  a  reliable  remedy 
for  infancy  and  childhood;  (2)  the  re- 
sults are  of  longer  duration  and  the  de- 
pression not  so  great  as  from  the  use  of 
antipyrine;  (3)  the  cyanosis  which  may 
accompany  its  use  is  not  dangerous  and 
soon  passes  away:  (4)  small,  but  re- 
peated, doses  should  be  used.  I.  N.  Love 
(Jour.  Amer.  Med.  Assoc,  Mar.  29,  '90). 
Acetanilid  habit  in  a  negro  adult  suf- 
fering from  rheumatism.  The  man  found 
that  he  was  relieved  by  its  administra- 
tion, but  that  on  leaving  off  the  drug  a 


70 


ACETANILID.     POISONING. 


few  days  the  pain  returned.     He  began 

taking  it  constantly  each  day  and  now 

uses  2   ounces   a  week.     G.   W.    Gaines 

(N.  0.  Med.  and  Surg.  Jour.,  July,  1900). 

Its  prolonged  administration,  even  in 

small  doses,  may  give  rise  to  sudden  and 

marked  antemia  and  to  temporary  mental 

aberration.  Experiments  in  animals  have 

shown  that  prolonged  use  tends  to  cause 

fatty  degeneration  of  the  heart,  liver,  and 

kidn€ys. 

Two  cases  in  which  gradual  loss  of 
memory  was  produced  by  long-continued 
administration  (5  to  30  grains)  of  ace- 
tanilid.  Memory  regained  by  stopping 
the  drug.  Joseph  Haigh  (Medical  World, 
Oct.,  '89). 

Report    of    twenty-five    physicians    of 
New  South  Wales.     Opinion  that  symp- 
toms of  depression  and  collapse  are  more 
readily  produced  and  are  more  marked 
than  with  antipyrine  may  be  explained 
by  the  fall  of  temperature  being  greater 
and   more   rapid.     Most   of   the   reports 
mention    cyanosis    to    a    greater    degree 
that  after  antipyrine.     Anaemia  may  be 
induced  by  its  continued  use  and  become 
a  grave  condition.    D.  R.  Paterson  (Prac- 
titioner, No.  304,  '93). 
Acetanilid  Poisoning.  —  Aeetanilid 
gives  rise  to  severe  symptoms  of  intox- 
ication more  frequently  than  any  other 
agent  belonging  to  the  aromatic  series, 
with  the  exception,  perhaps,  of  antipy- 
rine. 

When  poisonous  doses  are  taken,  there 
is  marked  cyanosis,  prostration,  shallow 
and  labored  respiration,  palpitation  of  the 
heart,  weak  and  thready  irregular  pulse, 
dilatation  of  the  pupils,  cold  extremities, 
subnormal  temperature,  cold  sweats,  and 
other  symptoms  of  collapse.  The  drug 
would  therefore  seem  to  be  a  depressant 
to  the  functions  of  respiration  and  cir- 
culation, with  disturbance  of  the  vaso- 
motor system  and  probably  of  the  heat- 
regulating  centres. 

Case  of  poisoning  by  acetanilid,  in  a 
lady  36  years  of  age,  who  had  taken 
about  40  grains  in  divided  doses,  in  the 


course  of  four  hours.  The  chief  symp- 
toms exhibited  were  semi-unconscious- 
ness; delirium;  a  very  feeble  pulse; 
short,  rapid  breathing;  cyanosis  of  face 
and  lips;  and  cold  extremities.  The 
patient  recovered  under  tlie  use  of  alco- 
holic stimulants  and  the  hypodermic  in- 
jection of  strychnine.  J.  W.  C.  (Med. 
Review,  May  21,  '92). 

Case  in  a  woman,  aged  21  years,  who, 
two  weeks  after  her  confinement,  was 
given,  for  headache,  V2  ounce  of  ace- 
tanilid in  bulk  in  an  envelope,  with 
directions  to  take  a  small  quantity  of  it 
on  the  end  of  a  teaspoon  every  two 
hours.  The  patient  took  two  doses  as 
directed,  and  a  few  hours  afterward,  the 
headache  still  persisting,  she  concluded 
that  a  very  large  dose  would  be  more 
efficacious,  and  swallowed  a  teaspoonful 
of  the  drug.  Half  an  hour  later  weak- 
ness and  dizziness,  and  an  hour  later  she 
fainted  and  passed  urine  involuntarily. 
Later  on  she  became  cyanotic  and  semi- 
conscious. The  pulse  was  slow  and  ex- 
tremely feeble,  the  respirations  slow  and 
shallow,  the  forehead  bathed  in  sweat, 
and  the  face  livid  and  perfectly  expres- 
sionless. The  tongue,  lips,  and  finger- 
nails were  intensely  cj'anotic  and  almost 
black;  the  head,  hands,  and  eyelids  were 
cold,  but  her  feet  were  quite  warm; 
temperature  was  normal;  there  was 
tingling  of  the  skin  over  the  entire  body 
and  some  slight  mental  confusion.  There 
was  suppi'ession  of  urine  until  noon  the 
next  day,  and  when  passed  it  was  of  a 
dark-brown  color  and  very  abundant. 
Loud  and  continuous  borborygmus 
noticed.  The  milk  secreted  by  the  breast 
was  very  much  thinner  than  it  had  been 
before  the  poisoning.  The  cyanosis  lasted 
for  several  da^'s.  Treatment  was  that 
advised  by  Hare:  Patient  forced  to 
maintain  a  recumbent  position,  the  head 
kept  low,  and  an  hypodermic  injection  of 
aromatic  spirit  of  ammonia,  followed  by 
sulphate  of  strychnine  and  sulphate  of 
atropine,  given.  Hot  bottles  placed  about 
the  body,  and  '/«  grain  of  strychnine 
every  three  hours  given  by  the  mouth, 
alternating  with  whisky  and  aromatic 
spirit  of  ammonia.  Owing  to  the  condi- 
tion of  the  milk,  it  was  not  considered 
wise  for  the  patient  to  continue  nursing 


ACETANILID.     POISONING. 


71 


her  child,  as  the  milk  failed  to  return  to 
its  normal  condition  after  recovery,  and 
the  patient  was  much  exhausted.  G. 
Baringer  Slifer  (Ther.  Gaz.,  May  15, '97). 

Case  of  acetanilid  poisoning  in  a 
woman,  aged  26  years,  who  had  taken 
8  grains.  Collapse  with  strong  convul- 
sive movements,  partial  loss  of  con- 
sciousness, and  great  retching.  Whisky, 
nitrate  of  strychnine,  and — for  two 
hours — artificial  respiration  induced  re- 
covery. 0.  R.  Summers  (N.  Y.  Med. 
Jour.,  Mar.  24,  1900). 

Case  of  fatal  acetanilid  poisoning. 
The  patient,  a  man  of  37,  had  taken 
six  "headache  powders"  each  contain- 
ing 10  grains.  He  became  delirious, 
complained  of  abdominal  pain,  vomited, 
and  was  slightly  jaundiced.  His  tem- 
perature rose  to  100.2°  F.,  the  lips  and 
nails  became  intensely  cyanotic,  respira- 
tions shallow  and  frequent.  The  urine, 
of  which  10  ounces  were  passed  on  ad- 
mission, was  nearly  black  and  strongly 
alkaline.  Anuria  occurred,  and  six  days 
later  the  man  died.  There  was  alter- 
nate constipation  and  diarrhoea,  and 
forty-eight  hours  before  death  the 
faeces  constantly  showed  blood-pigment, 
blood-clots,  and  corpuscles.  Philip 
Brown  (Amer.  Jour.  Med.  Sciences,  Dec, 
1901). 

Whik  subnormal  temperature  may 
result  from  the  administration  of  even 
small  doses,  it  is  not  always  present  in 
cases  of  poisoning. 

Subnormal  temperature,  in  a  man 
aged  40  years,  produced  by  a  second 
dose  of  7  grains  two  hours  after  the 
first.  T.  M.  Dunagan  (Memphis  Med. 
Monthly,  Mar.,  '91). 

The  toxic  properties  of  acetanilid  too 
often  appear  wnen  the  drug  is  given  in 
small  doses.  In  some  cases  symptoms 
become  so  severe  that  a  fatal  result  may 
be  imminent,  unless  prompt  treatment  is 
employed.  Having  been  widely  adver- 
tised as  a  universal  analgesic,  a  large 
number  of  remedies  for  the  relief  of  pain, 
under  catchy  titles,  contain  this  drug  as 
an  essential  ingredient.  Fifteen  grains 
is  commonly  considered  the  maximum 
dose,  yet  one-third  of  this  quantity  has 
been  personally  seen  to  produce  alarm- 


ing symptoms.  Authors  have  occasion- 
ally advised  that  3  grains  be  given  each 
hour,  but  patients  reach  the  danger-line 
long  before  the  maximum  quantity  was 
given  in  this  way.  Two  4-grain  doses 
caused  nearly  fatal  issue  in  a  case  in  an 
adult  described  by  O.  R.  Summers. 

Personal  case  in  which  the  patient  had 
taken  four  headache  powders.  The  head- 
ache powder  had  been  taken  each  hour, 
beginning  at  nine  o'clock  and  ending  at 
noon.  The  surface  of  the  body  presented 
an  ashen-gray  appearance,  the  mucous 
membranes  having  a  much  darker  hue. 
The  temperature  was  96  degrees;  pulse, 
60;  and  respiration,  10.  Digitalis, 
sti-ychnine,  and  alcohol-baths  with  fric- 
tion were  employed,  with  dry  heat  to  the 
surface.  AMien  the  patient  was  able  to 
swallow,  a  combination  of  aromatic 
spirit  of  ammonia,  brandy,  and  capsicum 
was  given.  Twenty-four  hours  later  the 
temperature  was  slightly  subnormal,  the 
dusky  appearance  of  the  face  disap- 
peared to  a  large  extent,  but  the  symp- 
toms of  cyanosis  did  not  wholly  vanish 
until  the  second  day.  The  powders  con- 
tained 3  grains  of  acetanilid,  2  grains  of 
bicarbonate  of  sodium,  and  1  grain  of 
caffeine;  hence  the  total  dose  was  12 
grains  of  acetanilid.  Conclusion  that 
under  no  circumstances  should  acetanilid 
be  administered  alone,  but  always 
guarded  by  a  cardiac  stimulant,  while 
the  intervals  between  doses  should  be 
sufficiently  prolonged.  Earps  (Merck's 
Archives,  June,  1901). 

The  cyanosis  is  probably  due  to  the 
liberation  of  free  aniline  in  the  blood, 
and  is  more  likely  to  occur  when  the 
acetanilid  is  imperfectly  manufactured. 
An  excess  of  aniline  is  present  when  the 
acetanilid  employed  gives  a  reddish- 
orange  precipitate  with  sodium  hydro- 
bromite. 

Many  of  the  toxic  symptoms  of  ace- 
tanilid so  closely  resemble  those  of 
aniline  poisoning  as  to  suggest  the  pro- 
duction of  that  substance  in  the  blood. 
There  is  a  close  relationship  between  the 
two  bodies,  and  there  is  therefore  some 
ground   to  suspect   the   occasional   pres- 


72 


ACETANILID.     POISONING. 


ence    of    aniline    in    samples.      Editorial 
(Brit.  Med.  Jour.,  Dec.  22,  '94). 

Cyanosis   is   due   to   the   liberation   of 
free  aniline  in   the  blood,  which   disap- 
pears  soon   afterward,   as  soon   as  it  is 
eliminated  by  the  kidneys  and  skin.     A 
similar     cyanosis,     though     more     pro- 
nounced,  is   found   in   the   workmen   of 
aniline-color    works.      C.    F.    Baohmann 
(N.  Y.  Med.  Jour.,  May  22,  '97). 
Aeetanilid  is  an  efiective  agent  for  the 
treatment  of  wounds,  causing  rapid  heal- 
ing in  subjects  whose  powers  of  resist- 
ance to  toxic  effects  are  not  greatly  bfilow 
par.     In  infants  and  aged  people,  for 
instance,  the   possibilities   of  untoward 
effects   are   greater   than   in   youths   or 
adult  subjects.     Idiosyncrasy  may  also 
enter  for  a  share  in  the  cases  of  poison- 
ing reported.    In  the  aged  the  resolutive 
process  may  be  retarded  by  its  use. 

Case  of  an  infant,  16  days  old,  suffer- 
ing from  haemorrhage  from  the  umbilicus. 
A  powder  of  equal  parts  of  boric  acid 
and  aeetanilid  applied  locally  twice  daily 
for  three  days  caused  the  face  to  become 
distinctly  cyanotic;  the  lips,  ears,  finger- 
tips, and  toes  bluish;  the  hands  and  feet 
cold ;  the  breathing  bordering  upon  ster- 
tor.  The  condition  disappeared  on  ceas- 
ing the  application  of  the  powder.  R.  C. 
Rosenberger  (Phila.  Polyclinic,  No.  45, 
'95). 

Case  in  an  infant,  aged  14  months,  in 
whom  excision  of  the  hip  had  been  per- 
formed for  tuberculosis  and  the  wound 
packed  with  aeetanilid.  In  four  hours 
the  temperature  dropped  five  degrees 
and  there  were  great  pallor  and  feeble 
pulse.  The  temperature  rose  and  symp- 
toms disappeared  upon  removal  of  the 
dressing.  The  second  case  was  one  of 
extensive  suppurative  superficial  scald. 
At  twelve  o'clock  2  drachms  of  finely- 
powdered  aeetanilid  were  dusted  over  the 
surface;  at  five  o'clock  the  patient  pre- 
sented grave  toxic  symptoms;  all  aee- 
tanilid Avas  at  once  removed,  digitalis 
and  whisky  were  exhibited,  and  by  mid- 
night he  was  in  a  normal  condition.  T.  S. 
K.  Morton  (Phila.  Polyclinic,  Feb.,  '95). 
Case  of  eczema  in  which  dusting- 
powder,   composed   of   1    part   aeetanilid 


and  3  parts  subnitrate  of  bismuth,  was 
used  three  times  a  day.  When  it  became 
necessary  to  secure  a  new  supply,  the 
second  application  produced  alarming 
cyanosis,  with  labored  breathing  and 
other  evidences  of  distress;  discontinu- 
ance of  the  powder.  Inquiry  showed 
that  cyanosis  had  followed  every  appli- 
cation of  the  powder.  Charles  Sauter 
(Louisville  Med.  Monthly,  Nov.,  '95). 

Two  cases:  an  amputation  of  the  ear 
for  epithelioma  of  the  helix  and  an 
abscess  of  the  maxillary  sinus  in  elderly 
men,  the  one  aged  73  and  the  other  84. 
Aeetanilid  seemed  to  produce  a  great 
deal  of  irritation  and  to  delay  granula- 
tion; similar  experience  several  times 
with  iodoform.  William  A.  Edwards 
(Pacific  Record,  Jan.  15,  '96). 

Marked  instance  in  an  infant  in  which 
it  had  been  applied  to  the  navel.  Face, 
lips,  fingers,  toes,  and  the  whole  of  the 
skin  and  visible  mucosa  of  a  dark-blue 
color.  Rectal  temperature  was  99°  P.; 
respiration,  60.  Oxygen,  whisky,  and 
digitalis  were  administered.  No  effect 
upon  cyanosis  noticed  from  the  oxygen 
inhalations.  Not  until  the  fourth  day 
did  the  child  regain  its  former  strength 
and  disposition.  I.  M.  Snow  (Archives 
of  Pediatrics,  June,  '97). 

In    obstetrics    aeetanilid    used    as    an 
antiseptic  in  all  injuries  occurring  in  the 
course  of  the  three  thousand  cases  seen 
by   her   since    1894.     It    always    caused 
rapid  resolution  of  the  woimd  without 
suppuration.     It  also  exerted  a  distinct 
analgesic  action,  which  was  particularly 
noticeable  in  the  painful  tears  in  the  re- 
gion of  the  clitoris,  the  urethra,  and  the 
vulva.    ProkopiefF  (Vratch,  xxi,  No.  14, 
1900). 
While  aeetanilid  forms  an   excellent 
dressing  for  wounds,  burns,  and  exposed 
surfaces  in  general,  it  is  easily  absorbed 
by  the  latter,  and  may  thus  give  rise  to 
active  toxic  symptoms,  especially  in  in- 
fants, as  shown  above. 

The     following     combination     recom- 
mended  in    numerous    diseases,   applied 
in  the  form  of  a  powder  or  a  paste: — 
1}  Aeetanilid,  3j. 
Zinc  oxide,  Siij. 
Iodized  starch  (5  per  cent.),  3iv. 


ACETANILID.    THERAPEUTICS. 


73 


The  iodized  starch  should  be  properly 
prepared  and  the  acetanilid  finely  pul- 
verized. SufiSoient  water  is  added  to 
make  a  paint  or  paste,  to  be  applied 
with  a  stiff  brush.  Liquid  albolene,  ben- 
zoin, or  olive-oil  may  be  used  instead 
of  water  when  the  application  is  in- 
tended for  dry  surfaces  or  ulcers;  a 
gauze  bandage  may  be  used  to  prevent 
it  from  being  rubbed  off.  When  dry 
the  powder  is  of  light-drab  color,  when 
wet  of  a  slate  color,  but  when  in  con- 
tact with  pus  it  turns  white,  showing 
that  the  iodine  has  been  liberated. 
This  combination  of  the  drugs  gives  an 
antiseptic,  astringent,  soothing,  and 
protective  remedy,  having  remarkable 
healing  properties,  useful  in  eczema, 
ulcers,  dermatitis  from  all  causes,  in- 
cluding superficial  burns,  impetigo,  sy- 
cosis, herpes  zoster,  and  chancroids.  T. 
G.  Lusk  (Jour,  of  Cutaneous  and  Genito- 
urin.  Dis.,  Dec,  1901). 

Treatment  of  Acetamlid  Poisoning. — 
In  the  treatment  of  poisoning  by  acetan- 
ilid cardiac,  respiratory,  and  vasomotor 
stimulation  is  of  great  importance. 
.  Ether,  hypodermically,  has  been  most 
frequently  used.  Belladonna  is  probably 
the  best  drug  to  fulfill  the  indications;  it 
tends  to  equalize  the  blood-pressure,  and 
with  external  warmth  and  some  more 
direct  cardiac  stimulant — brandy,  etc. — 
presents  the  needed  qualities  for  antago- 
nizing the  overaction  of  acetanilid. 

Therapeutics. 

Fever.  —  Acetanilid  presents  the  re- 
quired qualities  for  the  reduction  of  high 
fever,  which  alone  warrants  the  use  of 
antipyretics.  Not  only  is  a  rise  of  three 
or  four  degrees  harmless,  but  modern 
investigations  tend  to  show  that  it  is 
one  of  Nature's  means  of  defense  against 
pathogenic  elements  of  various  kinds. 
The  many  cases  of  marked  depression 
that  have  followed  its  use  even  in  moder- 
ate pyrexia  of  infectious  fevers  have 
caused  its  use  to  be  abandoned.  North- 
rup  severely  condemns  its  use  in  chil- 
dren. 


Malaria. — It  has  been  found  service- 
able by  several  observers  in  warding  off 
the  periodic  manifestations  of  intermit- 
tent fever. 

Acetanilid  possesses  great  merit  in 
warding  off  chills  in  intermittent  fever. 
If  there  is  time,  before  the  chill  1  Vs  to 
2  grains  of  calomel  in  Vi-grain  doses 
half  an  hour  apart  are  given;  then,  ac- 
cording to  age,  2  to  6  grains  of  ace- 
tanilid twenty  minutes  or  half  an  hour 
before  the  expected  chill.  Gentle  per- 
spiration with  natural  sleep  usually  fol- 
low within  half  an  hour;  if  not,  a  sec- 
ond dose  of  equal  amount  may  be  given. 
Used  in  several  hundred  cases  without 
quinine.  Benjamin  Brodnax  (North 
Carolina  Med.  Jour.,  Apr.  20,  '95). 

Typhoid  Fever.  —  Early  in  its  career 
acetanilid  was  found  more  harmful  than 
beneficial  in  this  affection.  It  tends  to 
depress  vital  energy,  which,  on  the  con- 
trary, should  be  sustained.  Its  use  in 
this  disease  has  been  practically  aban- 
doned. 

Classes  of  patients  who  exhibit  sus- 
ceptibility to  the  influence  of  acetanilid. 
In  a  number  of  cases  of  pregnant  and 
nursing  women  who  were  suffering  from 
typhoid  fever,  disagreeable  or  alarming 
symptoms  observed  to  follow  the  exhibi- 
tion of  any  but  very  moderate  doses  of 
the  drug.  Larger,  but  still  moderate, 
doses  were  frequently  followed  by  pro- 
fuse diaphoresis,  or  even  collapse.  Sem- 
britzki    (Ther.  Monat.,  June,  '89). 

Phthisis.  —  The  same  reasons  cause 
acetanilid  to  be  contra-indicated  in  this 
disease.  It  has  been  used  to  counteract 
the  afternoon  rise  of  temperature,  but 
the  advantage  gained  is  more  than  offset 
by  the  depression  produced. 

Case  of  a  young  man,  with  acute  pul- 
monary tuberculosis,  in  whom  10  grains 
produced  collapse.  James  Wilding 
(Brit.  Med.  Jour.,  Sept.  14,  '89). 

Nervous  Disordbes. — Pertussis. — It 
is  in  the  diseases  of  the  nervous  system 
that   acetanilid   has    shown    itself   most 


74 


ACETANILID. 


ACETIC  ACID. 


valuable.   As  an  antispasmodic  in  whoop- 
ing-cough its  effects  are  quite  marked. 

In  pertussis  it  lessens  the  discomfort 
and  keeps  the  paroxysms  in  cheek  better 
than  any  other  remedy.  I.  N.  Love 
(Jour.  Amer.  Med.  Assoc,  Mar.  29,  '90). 
Case  of  a  child,  5  years  old,  suffering 
from  pertussis,  who  took,  by  mistake,  1 
drachm  of  antifebrin.  Cyanosis;  res- 
pirations slowed.  Large  dose  had  an 
excellent  effect  on  the  whooping-cough. 
Spencer  (Canadian  Practitioner,  Apr., 
'91). 

Acetanilid  of  great  value  in  whooping- 
cough;    Vi  to  Va  grain  every  two  hours 
to  infants  1  to  2  months  old,  and  propor- 
tionately larger  doses  to  older  children. 
W.  L.  Wade  (So.  California  Pract.,  Aug., 
'94). 
Neuralgia  and  Kindred  Disorders.  — 
As  an  analgesic,  especially  in  cases  of 
neuralgic  or  neuritic  nature,  or  in  pain 
from  reflex  causes,  acetanilid  has  been 
of    marked    benefit.      In    rheumatism, 
sciatica,    lumbago,    trifacial    and    other 
neuralgias,     gastralgia,     girdle-pain     of 
locomotor  ataxia,  ovarian  or  other  vis- 
ceral pain,  the  pain  of  optic  neuritis  and 
glaucoma,  it  has  been  freely  used,  and 
still  maintains  a  well-deserved  reputa- 
tion.   It  is  also  effective  in  the  neuralgic 
pains  associated  with  herpes  zoster. 

Five-grain    doses    successfully    relieve 
the  lightning  pain  of  locomotor  ataxia. 
Stewart  (Canada  Med.  Record,  Jan.,  '88). 
Of  great  advantage   in   5-grain   doses, 
repeated    every    two   hours,    in    painful 
menstruation,  especially  of  young  girls. 
H.  B.  Ely  (Medical  World,  Jan.,  '91). 
Epilepsy. — In  epilepsy,  however,  it  has 
not  shown  itself  effective,  even  when  ad- 
ministered in  sufficiently  large  doses  to 
produce  cyanosis. 

Vomiting.  —  Vomiting  of  nervous 
origin  occasionally  yields  to  its  action. 
In  obstinate  vomiting,  particularly 
when  it  seems  to  be  due  chiefly  to  nerv- 
ous disturbance  or  marked  gastric  irri- 
tability. Two  grains  every  hour  until 
6   grains   are    taken   often   prevent   this 


unpleasant  sequel  of  operative  interfer- 
ence. H.  A.  Hai-e  (Therapeutic  Gazette, 
Nov.  15,  '94). 

ACETIC  ACID.  —  Acetic  acid  is  an 
organic  acid  obtained  from  vinegar,  of 
which  it  represents  the  active  principle. 
It  is  also  obtained  from  crude  pyrolig- 
neous  acid.  It  is  a  clear,  colorless  fluid 
having  a  strong  pungent  odor  and  an 
intensely-acid  corrosive  taste.  It  con- 
tains 36  per  cent,  of  glacial  acetic  acid: 
a  monohydrate  presenting  the  physical 
properties  of  acetic  acid,  which,  in  turn, 
becomes  crystalline  at  34°  F. 

Dose. — The  dilute  acetic  acid  is  offi- 
cinally  prepared  by  adding  1  part  of 
acetic  acid  to  5  of  water,  and  is  used  as 
a  local  astringent  and  stimulant. 

Glacial    acetic    acid    is    employed    as 
an  escharotic.     The  crystalline  form  is 
mainly  employed  with  sulphate  of  potas- 
sium in  the  preparation  of  smelling-salts. 
Experiments     to     ascertain     whethar 
acetic   acid   cannot   be   used   instead    of 
alcohol  to  avoid  the  dangers  of  the  alco- 
hol habit.     Nux  vomica,  kola,  cinchona, 
sanguinaria,  ipecacuanha,  and  colchicum- 
seed  successfully  exhausted  with  varying 
strengths  of  acetic  acid.    Joseph  P.  Rem- 
ington (Amer.  Jour,  of  Pharm.,  No.  3,  p. 
121,  '97). 

The  constituents  of  acetic-acid  prepa- 
rations may  be  divided  into  (a)  those 
which  hasten  the  evaporation  of  the 
acetic  acid  (this  group  includes  all  pow- 
dery substances — kieselgur  is  the  most 
active,  then  comes  kaolin;  sulphur  and 
flour  have  a  slighter  effect);  and  (6) 
those  which  retard  the  evaporation  of  the 
acetic  acid  (glycerin  comes  first,  then 
adeps  benzoatus,  and  lastly  vaselin). 
Following  preparations  of  acetic  acid 
recommended:  — 

1.  Adeps  lanse,  7  parts. 
Acetic  acid  (30  per  cent.),  7  parts. 
Benzoated  lard,  7  parts. 

2.  Adeps  lanse,  6  parts. 
Acetic  acid  (30  per  cent.),  7  parts. 
Benzoated  lard,  2  parts. 
Kaolin,  6  parts. 


ACETIC  ACID.     PHYSIOLOGICAL  ACTION.     THERAPEUTICS. 


75 


3.  Glycerin,  5  paits. 

Acetic  acid  (30  per  cent.),  7  parts. 
Kaolin,  9  parts. 
Following    "acetic  -  acid  -  and  -  sulphur 
paste"  is  very  useful  in  acne:  — 

4.  Adeps  lanae,  6  parts. 

Acetic  acid  (30  per  cent.),  7  parts. 
Benzoated  lard,  6  parts. 
Precipitated  sulphur,  2  parts. 
All  these  preparations  contain  10  per 
cent,  of  anhydrous  acetic  acid,  and  con- 
sequently are  strong  preparations  of  the 
acid.     Unna   (Treatment,  vol.  ii,  p.  373, 
'98). 
Physiological  Action.  —  In  free  dilu- 
tion acetic  acid  is  au  excellent  antiseptic; 
but,  administered  without  the  admixture 
•of  bland  liquids,  it  causes  intense  irrita- 
tion, owing  to  its  property  of  effecting  a 
partial  soltition  of  albuminous  bodies  and 
•of  dissolving  gelatinous  tissues.     Acetic 
acid  combines  with  the  alkaline  bases 
within  the  system,  forming  acetates  that 
are  diuretic  and  diaphoretic. 

Acetic- Acid  Poisoning.  —  The  escha- 
jotic  action  of  acetic  acid,  by  manifesting 
itself  upon  the  mucous  membrane  of  the 
pharynx  and  larynx,  is  liable  to  cause 
•oedema  of  the  glottis:  a  danger  to  be  at 
■once  thought  of.  The  immediate  mani- 
festations are  severe  pain  in  the  mouth, 
throat,  oesophagus,  and  stomach,  with 
retching  and  vomiting  and  other  symp- 
toms attending  violent  irritation  of  the 
■digestive  tract. 

Treatment  of  Acetic-Acid  Poisoning. — 
Alkalies  and  demulcents  should  be  em- 
ployed. The  bicarbonate  of  soda  in  free 
solution  is  an  effective  remedy.  Ordinary 
soap — one  containing  an  alkali — can  be 
used  in  solution  until  an  alkaline  salt  is 
■available. 

Therapeutics, — As  an  antiseptic,  acetic 
acid  is  possessed  of  considerable  power. 
As  such  it  may  either  be  applied  locally 
•or  its  fumes  may  be  inhaled. 

Good  effects  from  inhalations  of  a  2- 
to  3-per-cent.  solution  of  acetic  acid  in 


pachydermia  laryngis  associated  with 
tuberculosis.  Sittings  lasting  ten  min- 
utes three  times  a  day  and  continued 
several  weeks.  Scheinmann  (Berliner 
klin.  Woch.,  Nov.  21,  '91). 

Acetic  acid  an  excellent  remedy  in 
bronchitis  and  the  broncho-pneumonia  of 
children.  Used  in  forty  cases,  in  the 
form  of  inhalations.  The  acid  is  placed 
in  a  pan  held  over  a  lamp,  and  the 
patient,  seated  on  a  chair,  is  covered  over 
with  tents  made  of  sheets.  At  first  the 
lamp  should  be  turned  low,  to  avoid  un- 
due irritation  of  the  larynx  by  an  excess 
of  fumes.  To  be  used  ten  minutes  at  a 
time,  four  to  six  times  daily,  and  during 
the  night  in  the  sleeping-room.  B.  W. 
Switzer  (Med.  World,  Apr.,  '96). 

In  an  emergency  vinegar  is  useful  for 
disinfecting  the  hands  and  the  region 
operated  upon.  L.  Fiirst  (Deut.  Aerzte- 
Zeit.,  June  15,  1900). 

Acetic  acid  is  frequently  used  as  a 
stimulant.  When  inhaled  its  stimu- 
lating effects  upon  the  nervoiis  supply 
of  the  nasal  mucous  membrane  causes 
it  to  sometimes  act  rapidly  in  restoring 
consciousness  after  fainting.  In  the 
same  manner  it  may  also  arrest  vomiting 
and  headaches  of  nervous  origin. 

Vinegar  as  a  remedy  against  vomiting 
in  chloroform  narcosis.  Handkerchief 
moistened  with  vinegar  applied  to  the 
nostrils  and  permitted  to  remain  until 
patient  returns  to  consciousness.  War- 
holm  (Univ.  Med.  Jour.,  Dec,  '93). 

As  an  escharotic  it  is  often  used  on 
corns,  warts,  condylomata,  and  fungous 
growths.  The  glacial  acetic  acid  should 
be  used  for  this  purpose. 

Slcin  Diseases.  —  Acetic  acid  is  useful 
in  many  disorders  of  the  skin.  In  alo- 
pecia it  has  been  used  with  advantage  as 
a  vesicant. 

When  alopecia  is  extensive  the  scalp 
should  be  shaved  and  acetic  acid,  in 
greater  or  less  proportion,  mixed  with 
equal  parts  of  chloroform  and  ether,  ap- 


ACETIC  ACID. 


ACETONURIA. 


plied.      Or    Besnier's    formiila    may    be 
employed: —  ' 

19   Chloral  hydratis,  75  grains. 
JEtheris,  6  drachms. 
Acid,  acetic,  cryst.,  15  to  75  grains. 
M.     These  applications  are  repeated 
two  or  three  times  a  week  at  first  and 
later  at  long-er  intervals. 

Between-times  a  stimulating  oil — as  of 

eucalyptus  and  turpentine^   of  each,  V2 

ounce;    cnide  petroleum  and  alcohol,  of 

each,  1  ounce — is  applied.     This  is  to  be 

followed  by  a  thorough  massage  of  the 

scalp   for   five   minutes   by   the   patient. 

Once  a  week,  or  oftener,  the  scalp  is  to 

be  thoroughly  shampooed  with  tincture 

of  green   soap.     Morrow    (Jour,   of  Cut. 

and  Genito-Urin.  Dis.,  Oct.,  '91). 

In   rodent   nicer   and   Inpus    vulgaris 

acetic  acid  is  of  use;   but  in  the  latter 

affection  the  benefit  is  only  temporary. 

In  eleven  out  of  twelve  eases  ulcus 
rodens  observed  the  ulcer  was  situated 
upon  the  lower  lid.  Treatment,  by 
means  of  daily  applications  of  a  75-per- 
cent, solution  of  acetic  acid  and  subse- 
quent rinsing  with  water,  followed  by 
good  results.  Wagner  (Grafe's  Archiv  f. 
Oph.,  B.  33,  Ab.  3,  '91). 

In  rodent  ulcer.     Cure  of  a  young  girl 
attacked  with  vitiligo  of  the  body  and 
alopecia  of  the  scalp,  in  which  the  treat- 
ment   consisted    of   two    applications    of 
acetic    acid,    together    with    stimulating 
lotions  (tincture  of  rosemary,  Van  Swle- 
ten's  solution,   and  tincture  of  canthar- 
ides).     Feulard  (Le  Bull.  Mgd.,  Jan.  15, 
'93). 
Diseases  of   the  Nose   and   Throat. — 
Acute  coryza  is  sometimes  arrested  by 
the  inhalation  of  acetic  acid. 

Glacial  acetic  acid  is  useful  in  pre- 
venting the  development  of  hay  fever  by 
applications  to  the  nasal  mucous  mem- 
brane twice  per  week.  In  practically  all 
eases,  however,  the  applications  must  be 
renewed  each  year.     (Sajous.) 

In  hypertrophic  rhinitis  it  may  also  be 
used  in  the  same  way;  but  chromic  acid 
is  more  effective. 


In  tubercular  laryngitis  it  has  given 
good  results  in  arresting  ulceration.  The 
ulcers  are  first  scraped  and  the  acid  is 
then  applied  with  a  laryngeal  applicator. 

ACETONURIA.— Acetone  (C3HeO  = 
dimethylketone  ==  CH3— CO— CH3)  is  a 
thin,  watery,  very  movable,  odorless  liquid 
of  neutral  reaction.  It  has  a  curious  aro- 
matic odor,  resembling  somewhat  that  of 
acetic  ether  or  of  oil  of  peppermint.  It 
is  soluble  in  water,  in  alcohol  and  ether 
in  all  proportions;  evaporates  at  ordinary 
temperatures;  boils  at  56.5°  C;  and  has 
a  specific  gravity  of  0.81.  Acetone  can 
be  obtained  by  the  distillation  of  acetate 
of  barium.  Oxidation  of  acetone  causes 
the  formation  of  acetic  acid  and  formic 
acid.  As  a  product  of  metabolism,  it  was 
discovered  by  Fetters,  in  1857,  in  the 
urine  of  a  diabetic  patient. 

Acetone  is  found  in  the  urine  of 
healthy  individuals  in  quantities  not  ex- 
ceeding 10  milligrammes  per  day,  which, 
during  starvation  (Mliller),  can  increase 
to  780  milligrammes  per  day.  In  some 
diseases  it  increases  to  0.8  to  0.5  gramme 
daily.  By  distilling  the  urine  examined, 
acetone  can  be  obtained  in  a  purer  state, 
although  still  united  with  other  volatile 
constituents  of  the  urine. 

Physiological  and  Pathological  Ex- 
cretion of  Acetone.  —  Pathological  ace- 
tonuria  is  observed  (1)  in  fevers,  (2)  in 
diabetes,  (3)  in  some  forms  of  carcinoma 
which  have  not  as  yet  induced  inanition, 
(4)  in  psychoses,  (5)  in  autointoxications, 
and  (6)  in  different  disorders  of  the 
digestion.  Lorenz  observed  acetonuria 
and  excretion  of  acetone  with  the  fseces 
and  the  vomited  matter  in  a  case  of 
peritonitis.  In  fevers  acetonitria  is  con- 
stantly observed,  and  in  the  fevers  of 
children  as  well  (Baginsky).  In  cases  of 
diabetes,  acetonuria  occurs  when  the  dis- 
ease has  continued  for  a  long  time,  and 


ACETONURIA.     ORIGIN  OF  ACETONE. 


especially  when  the  patients  are  put  on 
an  exclusive  diet  of  proteids  or  proteids 
and  fat,  or  when  the  allowance  of  food  is 
not  sufficient  to  maintain  the  equilib- 
rium of  metabolism. 

In  fevers,  as  well  as  in  diabetes,  ace- 
tonuria  is  often  accompanied  by  excre- 
tion of  diaeetic  acid  and  beta-oxybutyric 
acid. 

The  Origin  and  Pathological  Signifi- 
cance of  Acetone,  Diacetic  Acid,  and 
Beta-oxybutyric  Acid.  —  The  origin  of 
acetone  in  the  organism  has  not  yet  been 
ascertained.  Cantani  was  of  the  opinion 
that  it  was  formed  in  functional  disor- 
ders of  the  digestive  tract;  Fetters  and 
Kaulich  argued  that  it  was  due  to  fer- 
mentations in  the  bowels.  MarkownikofE 
ascribed  it  to  a  fermentative  product  of 


Aeetonuria  of  intestinal  origin  cannot 
be  denied;  but  its  occurrence  from  tliis 
cause  is  probably  much  rarer  than  many 
have  imagined.  S.  Boeri  (Revista  Clin, 
e  Terapeutica,  Nov.,  "91). 

The  development  of  aeetonuria  from 
affections  of  the  intestines  of  the  most 
varied  character  is  a  phenomenon  so  con- 
stant that  it  would  be  well  to  add  to  the 
already  recognized  varieties  of  the  con- 
dition a  class  caused  by  intestinal  dis- 
turbances. In  these  cases  of  digestive 
fault  it  seems  impossible  to  separate 
aeetonuria  and  diaceturia,  in  that  the 
differences  in  clinical  manifestations  be- 
tween these  substances  are  but  slight, 
and  really  only  quantitative  in  charac- 
ter, and  the  combination  or  alternation 
of  the  two  conditions  is  almost  always 
the  case.  The  symptoms  formerly  attrib- 
uted to  these  substances  do  not  appear 
to  be  due  to  them,  but  to  lower  oxidized 
forms.  When  albuminuria  exists  it  does 
not  seem  to  be  in  any  way  dependent 
upon  either  of  these  substances.  Ace- 
tone is  to  be  found  (sometimes  in  large 
amounts)  in  the  contents  of  the  stomach 
and  intestine  in  many  cases.  There  is  a 
great  difference  between  the  primary  and 
secondarv    gastro-intestinal    affections, 


especially  of  nervous  origin;  in  the  for- 
mer the  gastric  contents  almost  always 
contain  acetone;  in  the  latter  it  is  rarely 
found.  In  several  cases  oxybutyric  acid 
was  also  found  in  the  urine.  Lorenz 
(Oesterr.-ungar.  Cent.  f.  d.  med.  Wissen., 
'91). 

Experiments  to  ascertain  whether 
Mayer's  view  that  aeetonuria  is  an  evi- 
dence that  an  acid  intoxication  of  the 
organism  exists  are  correct. 

Strychnine  poisoning  produced  in  a 
number  of  dogs,  thus  causing  an  acid  in- 
toxication through  the  muscular  spasm. 
In  no  instance  was  aeetonuria  the  result. 

Acetone  looked  for  in  31  epileptics  also, 
after  convulsions,  and  found  in  only  13 
instances  and  in  but  small  quantities; 
several  of  these  patients  had  acetone  in 
their  urine  before  the  convulsions. 

To  see  whether  acetone  comes  from  the 
gastro-intestinal  tract  calomel  was  given 
to  a  diabetic  girl  that  showed  aeetonuria. 
Were  the  acetone  formed  in  the  gastro- 
intestinal tract  it  would  seem  probable 
that  after  the  disinfecting  and  purgative 
action  of  the  calomel  the  quantity  of  the 
urine  would  be  less.  On  the  contrary, 
the  amount  was  rather  greater  than  less, 
and  at  any  rate  it  was  not  decreased. 
Hugo  Liithje  (Centralb.  f.  innere  Med., 
Sept.  23,  '99). 

The  necessary  condition  for  the  pro- 
duction of  aeetonuria  is  an  insufficient 
decomposition  of  hydrocarbons,  either 
from  their  absence  in  the  diet  or  from 
impaired  powers  of  decomposition  on  the 
part  of  the  organism  (diabetes).  In  ad- 
vanced diabetes  aeetonuria  is  a  grave 
symptom,  threatening  coma.  This  coma 
may  be  delayed  by  the  administration  of 
large  doses  of  sodium  bicarbonate.  It  is 
probable  that  the  bodies  of  the  acetone 
series  are  formed  in  considerable  quantity 
in  the  organism,  to  disappear  completely 
later.  They  doubtless  represent  links  in 
a  continuous  series  of  transformations  in 
which  oxybutyric  acid-beta  is  the  pri- 
mordial term.  H.  C.  Geelsuyden  (Norsk 
Mag.  f.  Laegevidensk.,  July,  1900). 

Albertoni  did  not  find  acetone  in 
the  urine  of  animals  which  had  received 
large  doses  of  glucose  (100  grammes)  or 


78 


ACETONURIA.     ORIGIN  OF  ACETONE. 


of  difEerent  primary  saturated  alcohol; 
when  isopropylalcohol  was  ingested  it 
was  excreted  partly  unaltered  and  partly 
changed  to  acetone,  and  when  acetone 
was  given  to  animals  it  was  discharged 
by  the  urine,  even  if  the  dose  of  acetone 
ingested  did  not  exceed  8  centigrammes. 
When  Gerhard  detected  the  presence, 
in  the  urine,  of  a  substance  which  gave 
a  dark,  wine-red  color  by  means  of  a 
solution  of  perchloride  of  iron,  he  be- 
lieved this  substance  to  be  diacetic  ether, 
and  was  of  the  opinion  that  acetone  was 
derived  from  this  substance,  which  can 
easily  be  disintegrated  into  acetone,  alco- 
hol, and  carbonic  acid.  Fleischer  and 
Tollens  proved  this  to  be  an  error,  and 
found  that  the  coloring  substance — at 
least,  in  the  majority  of  cases — must  be 
diacetic  acid,  which  can  be  separated 
from  the  urine  by  the  addition  of  sul- 
phuric acid  and  extracted  with  ether. 
This  opinion  is  supported  by  von  Jaksch. 
Minowski  caused  acetonuria  by  extir- 
pation of  the  pancreas,  and  von  Mering 
by  intoxication  with  phloridzin. 

Lustig  foimd  that  extirpation  of  the 
solar  plexus  in  animals  provoked  ace- 
tonuria, glycosuria,  and  emaciation, 
while  Oddi  obtained  the  same  results  by 
sugar  injections. 

Acetonuria  may  not  depend  upon  the 
extirpation  of  the  cceliae  plexus.     It  is 
to    be    noted    that   septic    peritonitis    is 
avoided  with  difficulty.     Acetonuria  ob- 
served for  three  days  in  a  woman  oper- 
ated  on   for   salpingitis.     On   the   other 
hand,  it  was  not  met  Avith  in  a  dog  which 
had  undergone,  under  all  antiseptic  pre- 
cautions, subdiaphragmatic  section  of  the 
vagus   and   e.xtirpation    of    the    ganglia. 
Contejean    (Archives   de   Phys.     Brown- 
Sequard,  Oct.,  '92). 
Lorenz  is  of  the  opinion  that  diacetic 
acid  and  the  beta-oxybutyric  acid  are  the 
sitbstances  from   which  acetone  is   de- 
rived, and  that  they  are  the  real  causes 
of  the  toxic  symptoms  observed  in  ace- 


tonuria, while  acetone  itself  is  relatively 
innocuous. 

Von  Engel  found  a  great  quantity  of 
acetone  in  the  urine  of  a  patient  suffer- 
ing from  lactonuria;  when  the  milk  was 
removed  by  a  suckling  apparatus  the 
acetonuria  disappeared.  Very  much  ace- 
tone was  found  in  the  urine  of  patients 
suffering  from  severe  chronic  morphin- 
ism. In  different  acute  fevers  aceto- 
nuria is  rather  a  constant  symptom;  in 
typhoid  fever  von  Engel  found  it  con- 
stantly; acetone  was  only  missed  when 
the  typhoid  fever  was  accompanied  by 
obstipation. 

Acetonuria  occurs  not  infrequently  in 
children,  especially  in  febrile  affections 
and  in  acute  gastro-intestinal  derange- 
ments. It  may,  however,  be  absent  even 
in  high  and  continuous  pyrexia.  Diace- 
turia,  likewise,  is  frequent  in  children, 
and  is  almost  constant  in  high  and  con- 
tinued fever;  and  is  common  in  the 
acute  infectious  processes,  even  if  there 
be  but  little  attendant  fever, — as,  too,  is 
the  case  with  acetonuria.  Schrack  (Fort- 
sehritte  der  Med.,  Oct.  1,  '89). 

Acetonuria  was  studied  in  twenty-six 
cases.  In  physiological  pregnancy  at  the 
ninth  month  acetonuria  is  more  marked 
than  in  the  non-pregnant  state.  In  labor 
the  acetonuria  increases,  especially  if  the 
parturition  be  prolonged.  In  the  puer- 
perium  it  diminishes,  remaining,  how- 
ever, greater  than  in  pregnancy  till  after 
the  sixth  day.  The  view  that  acetonuria 
can  be  regarded  as  a  sign  of  fcetal  death 
is  not  sustained.  R.  Costa  (Ann.  di 
Ostet.,e  Gynec,  xxiii.  Mar.,  1901). 

Becker  found  that  acetonuria  increased 

after  narcosis,  the  case  being  the  same 

with  an  already  existing  acetonuria.  This 

would  seem  to  explain  why  acetonuria 

has  been  observed  after  great  operations. 

Operations  are  frequently  followed  by 

acetonuria,   but,   contrary   to   what   has 

been  claimed,  this  is  not  the  result  of 

opening  the  peritoneum  or  of  the  use  of 

sublimate.    It  also  causes  no  pathological 

reaction.     Though  traces  of  acetone  may 

be  met  with  in  normal  persons,  this  is 


ACETOXURIA.     ORIGIN  OF  ACETONE. 


7» 


not  always  the  case,  and  it  cannot,  there- 
fore, be  regarded  as  a  necessary  product 
of  metabolism.  Conti  (Wratsch,  Dec.  7, 
'93). 

In  healthy  subjects  after  narcosis  ace- 
tonuria  sets  in,  lasting  from  a  few  hours 
to  several  days.  This  post-narcotic  aee- 
tonuria  indicates  an  increased  destruc- 
tion of  albumin.  Ernst  Becker  (Vir- 
ehow's  Archiv  f.  Path.  Anat.  and  Phys. 
u.  f.  klin.  Med.,  Apr.  2,  '95). 

Acetonuria  follows  anaesthesia  in  two- 
thirds  of  the  caseSj  the  ansesthetie  used 
making  no  difference;  if  acetonuria  is 
present  before,  anaesthesia  increases  it.  ' 
The  practical  outcome  is  that,  except  in 
eases  of  urgency,  ansesthetics  should  not 
be  administered  to  diabetic  patients. 
Abram  (Jour.  Path,  and  Bac,  p.  3,  430, 
'96). 

Marked  and  prolonged  acetonuria  de- 
tected during  retrogression  of  fibroids 
after  oophorectomy  or  ligature  of  the 
ovarian  arteries.  Bossi  (Arch,  di  Ostet.  e 
Ginec,  vol.  iv,  p.  4,  '98). 

Acetone,  diaeetic  acid,  and  beta-oxy- 
butyrie  acid  are  found  in  great  quanti- 
ties in  the  urine  of  diabetic  coma,  and 
different  authors — Mnnser  and  Strassez, 
for  instance — believe  these  substances  to 
be  the  real  cause  of  coma,  perhaps  by 
causing  an  excess  of  acidity  in  the  or- 
ganism. 

In  comatose  patients  who  do  not  suffer 
from  diabetes — as,  for  instance,  in  satur- 
nine encephalopathies,  etc. — diaeetic  acid 
is  often  found  in  the  urine.  Von  Jaksch 
has  proposed  to  give  the  name  of  "coma 
diaceticum"  to  these  case's  of  coma. 
Nevertheless,  neither  acetone  nor  dia- 
eetic acid  and  oxybutyric  acid  have  very 
prominent  poisonous  properties.  Kuss- 
maul  gave  animals  6  grammes  of  acetone 
per  day  without  effect.  Buhl,  Tappeiner, 
and  Frerichs  came  to  similar  results. 
Albertoni  found  the  lethal  dose  of  ace- 
tone for  dogs  to  be  about  6  to  8  grammes 
per  kilogramme  of  the  dog's  weight. 

Case  of  cerebral  apoplexy  in  which 
sugar  and  acetone  were  detected  in  the 


urine.  The  coma  had  come  on  suddenly, 
and  was  regarded  as  diabetic  from  the 
urinaiy  condition;  but  the  autopsy  re- 
vealed an  extensive  cerebral  haemorrhage. 
Ruttan  and  Johnston  (Montreal  Med. 
Jour.,  Mar.,  '91). 
Geelsuyden  draws  the  conclusion  from 
many  experiments  on  rabbits  that,  even 
when  small  (10  to  20  milligrammes} 
subcutaneous  injections  of  acetone  are 
given,  the  acetone  is  excreted  with  the 
urine;  in  larger  doses  more  acetone  i& 
excreted;  but  only  a  portion  of  the  in- 
jected quantity  reappears;  another  por- 
tion of  it  is  excreted  with  the  expired 
air;  but  still  a  portion  is  left  which  does- 
not  reappear  and  must  therefore  have 
been  disintegrated  in  the  body  of  the 
animal.  After  the  injections  albumi- 
nuria takes  place.  An  adult  rabbit  can 
bear  an  injection  of  2  grammes  of  ace- 
tone, but  is  killed  by  the  injection  of  S 
grammes.  In  starving  auimals  the  ex- 
periments gave  the  same  results;  a  por- 
tion of  the  injected  acetone  reappeared 
in  the  urine  and  the  expired  air,  while- 
still  another  portion  was  disintegrated  in 
the  body.  Geelsuyden  draws  from  these 
experiments  the  conclusion  that  the  ace- 
tonuria observed  in  starving  individuals- 
is  not  caused  by  a  diminution  of  the- 
power  to  disintegrate  acetone  already 
formed  in  the  bodj',  but  to  an  increase- 
of  the  amoimt  of  acetone  formed  in  the- 
body. 

Modern  authors  generally  admit  that 
acetone  is  a  product  of  the  metabolism 
of  proteids.  Honigmann  and  von  Noor- 
den  are  of  the  opinion  that  acetone  is 
only  formed  by  diminution  of  the  organ- 
ized albumin  of  the  body,  and  never  by 
the  metabolism  of  the  proteids  ingested 
with  the  food,  be  the  quantity  ever  so 
large.  Honigmann  supported  this  theory 
principally  by  experiments  made  on  him- 
self, which  proved  that  when  he  lived 
exchi.sively  on  large  quantities  of  proteids- 


ACETONURIA.     ORIGIN  OF  ACETONE. 


— that  iSj  when  nutrition  was  insufficient 
— acetone  and  diacetie  acid  were  found. 
The  acetonuria  was  not  augmented  when 
more  albumin  was  ingested,  but  disap- 
peared when  he  took  plenty  of  carbohy- 
drates in  addition  to  the  proteids.  Von 
Engel,  on  the  contrary,  is  of  the  opinion 
that  in  all  cases  when  great  quantities 
of  albumin  are  decomposed  in  the  body 
the  quantity  of  acetone  excreted  with  the 
urine  will  increase  considerably, — equally 
if  the  albumin  is  ingested  with  the  food 
or  taken  from  the  stock  of  the  body. 

Relations  existing  between  patholog- 
ical acetonuria  and  azoturia  in  several 
diseases  (diabetes  mellitus,  typhoid  fe- 
ver, pneumonia,  phosphorvis  poisoning)  : 
acetone  seems  to  increase,  especially  in 
those  cases  where  destruction  of  albumi- 
noid matters  is  also  increased,  whether 
they  be  of  organic  nature  or  belong  to 
the  albumin  of  alimentation.  A  direct 
proportion  between  the  amounts  of  ace- 
tone and  albumin  has  not  been  observed. 
A  solution  between  the  two  is  some- 
times observed,  but  it  is  by  no  means 
constant.  Palma  (Jour,  de  Med.  de  Chir. 
et  de  Pharm.  Bruxelles,  Feb.  2,  '95). 

Twenty-six  cases  of  acetonuria  stud- 
ied. In  physiological  pregnancy  at  the 
ninth  month  the  acetonuria  is  more 
marked  than  in  the  non-pregnant  state. 
In  labor  the  acetonuria  increases,  espe- 
cialh'  if  the  parturition  be  prolonged. 
In  the  puerperium  it  diminishes,  remain- 
ing, however,  greater  than  in  pregnancy 
till  after  the  sixth  day.  The  view  that 
acetonuria  can  be  regarded  as  a  sign  of 
foetal  death  is  not  sustained.  R.  Costa 
(Ann.  di  Ostet.  e  Gynec,  xxiii,  March, 
1901). 

Weintraud  and  Hirschfeld  are  decided 
opponents  of  this  theory.  Weintraud 
argues  that — in  a  case  of  severe  diabetes 
where  complete  equilibrium  of  the  me- 
tabolism, and  especially  of  the  metabo- 
lism of  nitrogen,  was  maintained  for  a 
long  time,  so  that  no  albumin  contained 
in  the  tissues  was  consumed — acetone, 
diacetie  acid,   and  beta-oxybutyric  acid 


were  constantly  excreted  with  the  urine; 
the  diet  was  free  from  carbohydrates; 
when,  also,  the  quantity  of  proteids  was 
somewhat  reduced  the  sugar  disappeared 
after  twenty-four  hours;  the  weight  of 
the  body  was  maintained,  but  acetone 
and  diacetie  acid  were  still  excreted. 

Carbonate  of  soda  augmented  the 
quantity  of  acetone  excreted,  without 
diminishing  the  quantity  of  oxybutyric 
acids.  When,  in  periods  of  twenty-four 
hours,  no  food  at  all  was  taken,  ace- 
tonuria was  greatly  increased.  Inges- 
tion of  carbohydrates  diminished  the 
acetonuria  even  in  persons  suffering  from 
diabetes;  levulose,  milk,  and  sugar  have 
the  same  property;  glycerin,  also,  as 
observed  by  Hirschfeld.  The  addition 
of  fat  to  the  food  has  no  power  to  arrest 
the  acetonuria. 

Hirschfeld  found  that  when  he  put 
two  individuals  on  light  diet,  consisting 
only  of  proteids  and  fat,  diminution 
of  albumin  of  the  body,  as  well  as  ace- 
tonuria, was  produced.  When  carbohy- 
drates were  added  to  the  food  the  ace- 
tonuria diminished,  and  that  to  a  much 
greater  degree  than  the  diminution  of 
albumin.  Ingestions  of  fat  had  abso- 
lutely no  influence  in  diminishing  ace- 
tonuria, although  it  diminished  the  loss 
of  nitrogen.  Acetonuria  is  more  marked 
when  the  albuminous  food  is  scarce  than 
when  it  is  given  in  great  quantities.  The 
ingestion  of  carbohydrates  has  an  extra- 
ordinarily rapid  effect  on  the  production 
of  acetonuria,  the  quantity  of  acetone 
being  considerable  within  two  hours. 
Experiments  in  persons  who  were  almost 
starving  have  proved  that  a  moderate 
quantity  of  carbohydrates  was  sufficient 
to  bring  about  marked  diminution  of  ace- 
tonuria in  spite  of  the  considerable  loss 
of  albumin  and  fat  which  still  took  place. 
Objections  to  the  view  that  pathologi- 
cal acetonuria  is  due  to  autointoxication. 


ACETONURIA.     TESTS  FOR  ACETONE. 


81 


It  was  formerly  thought  that,  apart  from 
diabetes,  acetonuria  might  occur  in  the 
fasting  state,  in  fever,  and  in  special  dis- 
eases, such  as  carcinoma.  The  increased 
production  of  acetone  was  loolced  upon 
as  the  result  of  increased  albuminous  de- 
composition. This  rests  on  a  false  basis. 
It  was  known  that  acetone  was  present 
in  the  urine  in  people  fed  exclusively  on 
albuminous  foodstuffs  and  fat,  and  that 
the  increase  disappeared  when  carbohy- 
drates were  taken.  The  author  showed 
that  even  small  quantities  of  carbohy- 
drates had  a  very  considerable  eifect  on 
the  acetone  excretion;  that  the  acetonu- 
ria found  in  febrile  affections  and  in  car- 
cinoma could  be  made  to  disappear  when 
abundant  carbohydrate  foodstuffs  were 
given,  and  that  it  increased  when  the 
patient  could  eat  less.  The  question  of 
acetonuria  in  diabetes  is  in  accord  with 
the  view  of  its  connection  with  carbo- 
hydrate metabolism.  There  is  very  little 
difference  between  the  healthy  and  dia- 
betics, as  long  as  the  latter  can  deal  with 
the  largest  part  of  the  carbohydrate  food- 
stuffs supplied,  but  when  the  carbo- 
hydrates are  excreted  as  sugar  the  ace- 
tone in  the  urine  is  increased.  The 
difference  between  the  healthy  and  dia- 
betics is  that  in  the  latter,  notwithstand- 
ing abundant  carbohydrate  foodstuffs, 
acetone  excretion  is  abundant,  and  that, 
whereas  in  the  healthy  the  acetone  in 
the  urine  does  not  exceed  0.9  gramme,  in 
the  diabetic  it  is  much  above  1  gramme. 
It  is  only  correct  to  speak  of  a  patho- 
logical acetonuria  in  diabetes.  Hirsch- 
feld  (Cent.  f.  inn.  Med.,  June  13,  '96). 

Geelsiiyden,  from  his  experiments  on 
rabbits  and  dogs  already  mentioned, 
readied  the  conclusion  that  acetone  is 
formed  in  the  tissues,  not  in  the  kid- 
neys; that  the  kidneys  give  passage  to 
the  acetone  even  when  their  blood  con- 
tains a  very  small  quantity  of  it;  and 
that  pathological  acetonuria  is  not  caused 
by  a  defect  of  disintegration  of  acetone 
in  the  body,  but  by  a  disorder  of  the 
general  metabolism  leading  to  the  for- 
mation of  an  anomalous  large  quantity 
of  acetone.    Geelsuvden  has  further  con- 


ducted a  series  of  experiments  in  healthy 
individuals  (medical  students)  put  on  dif- 
ferent scales  of  diet,  which  were  strictly 
controlled.  As  all  observers  did,  Geel- 
suyden  found  that  when  a  person  was 
put  on  exclusive  flesh  diet  acetonuria 
appeared,  and  at  the  same  time  the  body 
lost  albumin  as  well  as  fat;  when  large 
quantities  of  proteids  were  ingested,  ace- 
tonuria was  less  considerable  than  when 
less  albumin  was  given.  Complete  star- 
vation, an  exclusive  fat  diet,  and  a  diet 
of  proteids,  with  the  addition  of  a  great 
quantity  of  fat,  cause  a  very  considerable 
amount  of  acetone  to  be  excreted.  As 
exclusive  diet  of  fat  and  complete  star- 
vation give  rise  to  the  excretion  of  the 
largest  quantity  of  acetone,  it  seems  that 
acetone  is  formed  by  disintegration  of 
fat,  and  that  in  this  respect  there  is  no 
difference  between  the  fat  of  the  food 
and  that  of  the  tissues.  Carbohydrates 
have  a  great  power  to  check  the  excre- 
tions of  acetone;  when  individuals  were 
put  on  a  diet  without  carbohydrates  and 
secreted  itrine  containing  a  great  quan- 
tity of  acetone,  the  acetonuria  disappeared 
in  a  few  hours  when  carbohydrates  were 
given.  From  150  to  200  grammes  of 
carbohydrates  per  day  are  required  to 
check  an  already  existing  alimentary 
acetonuria. 

In  the  opinion  of  Geelsuyden,  ace- 
tonuria occurs  when  carbohydrates  are 
not  ingested  in  sufficient  amount,  and 
acetone  is  formed  by  the  disintegration 
of  fat,  either  of  that  of  the  tissues  or  of 
that  contained  in  the  food. 

Preliminary  Tests  for  Acetone. — With 
an  alkaline  solution  of  sodium  nitrocy- 
anide  (of  a  slightly-red  hue)  acetone 
gives  a  ruby-red  color,  changing,  after 
some  time,  to  yellow,  and  after  acidifying 
with  acetic  acid  and  boiling,  to  greenish- 
violet. 

The  cyanide-of-soda  test,  after  Legal 


82 


ACETONURIA.     TESTS  FOR  ACETONE. 


or  le  Nobel  (see  below),  may  be  employed 
as  preliminary  test;  but,  to  make  the 
presence  of  acetone  positive,  it  is  neces- 
sary to  separate  it  from  the  urine  by 
distillation.  As  the  boiling-point  of  ace- 
tone is  low  (56°  C),  this  may  be  done 
at  a  low  temperature,  and  the  use  of  a 
water-bath  is  recommended. 

Legal's  Test.  ■ —  To  ten  cubic  centi- 
metres of  urine  a  small  crystal  of  nitro- 
cyanide  of  soda  or  some  drops  of  a 
freshly-made  solution  of  this  reagent  are 
added;  the  fluid  is  rendered  strongly 
alkaline  by  a  30-per-cent.  solution  of 
caustic  soda  or  potash.  When  acetone  is 
present  a  beautiful-red  color  will  appear, 
which  will  change  only  after  some  time 
to  yellow;  the  red  color  produced  in 
the  same  manner  by  creatinin  becomes 
yellow  sooner.  Legal  adds  that,  when 
acetone  is  present  and  the  urine,  shortly 
after  the  addition  of  the  solution  of  soda, 
is  neutralized  with  acetic  acid,  the  urine 
assumes  a  purple-red  color,  and,  when 
diluted  with  water,  a  crimson  hue.  When 
the  acetic  acid  is  floated  on  the  urine  a 
crimson  ring  will  appear  at  the  point 
of  contact,  and,  when  much  acetone  is 
present,  the  color  of  the  ring  will  be 
purplish  red. 

Le  Nobel's  Test.  —  Le  Nobel  and 
Fehr  hold  that  Legal's  test  is  only  re- 
liable when  much  acetone  is  present; 
and  that,  when  there  is  only  a  small 
quantity  of  it  in  the  urine,  the  test  may 
be  fallacious,  since  other  substances  con- 
tained in  the  urine  can  produce  a  red 
color  with  the  nitrocyanide  of  soda.  The 
most  characteristic  point  of  the  test  is, 
according  to  Fehr,  the  appearance  of  the 
violet  hue,  which  causes  the  red  color  to 
become  crimson  or  purple,  and  not  pure 
red. 

Le  Nobel  proposes  to  substitute  a  solu- 
tion of  ammonia  for  the  solution  of  soda, 
when  the  test  is,  in  other  respect,  made 


according  to  the  indications  of  Legal; 
■the  fluid  containing  acetone  is  not  im- 
mediately colored,  but  after  some  time, 
when  the  liquid  is  shaken  with  air  or 
some  drops  of  a  strong  acid  added  (the 
alkaline  reaction  being  maintained),  the 
fluid  takes  a  rose-red  color,  increasing 
gradually  and  changing  after  some  time 
to  violet  wine-red.  By  heating  the  fluid 
the  color  disappears,  but  returns  on 
cooling  down;  when  boiled  with  acids  it 
changes  into  greenish  violet.  Le  Nobel's 
test  is  more  delicate  than  Legal's,  and 
will  reveal  0.00025  gramme  of  acetone. 

Fehr's  Test. — Fehr  also  employs  the 
test  after  the  method  of  Legal,  but  pro- 
poses, when  the  color  of  the  imne  after 
the  addition  of  solution  of  soda  is  pass- 
ing from  dark  red  to  yellow,  to  float 
some  drops  of  acetic  acid  on  the  urine. 
When  the  test-tube  is  slightly  rotated  so 
that  only  a  small  quantity  of  the  acid 
mingles  with  the  urine,  a  beautiful  violet 
color  will  appear  when  acetone  is  pres- 
ent, the  intensity  of  the  color  being  pro- 
portionate to  the  quantity  of  acetone 
contained  in  the  urine. 

Chautaed's  Test.  —  Eomine  recom- 
mends, as  a  reliable  test  for  acetone  in 
the  urine,  a  solution  of  fuchsin  (1  to 
2000)  into  which  a  current  of  sulphur- 
ous-acid gas  has  been  passed.  This  rap- 
idly decolorizes  the  liquid  and  causes  it 
to  assume  a  clear-yellow  tint,  which  is 
permanent  and  unaifected  by  an  excess 
of  acid.  A  few  drops  of  such  a  solution, 
added  to  a  urine  containing  acetone, 
produce  a  deep-violet  color.  The  test  is 
delicate  enough  to  allow  the  detection 
of  one  part  of  acetone  in  one  thousand 
of  urine. 

Definite  Tests  for  Acetone. — When  no 
very  great  quantity  of  acetone  is  found 
in  the  urine  it  is  absolutely  necessary  to 
distill  the  urine  and  to  test  the  distillate 
with  the  different  reagents.    The  distilla- 


ACETONURIA.     TESTS  FOR  ACETOXE. 


83 


tion  of  two  hundred  to  three  hundred 
cubic  centimetres  of  urine  is  made  in  a 
water-bath,  and  a  temperature  of  56° 
to  58°  C.  is  employed.  No  acid  need  be 
added  to  the  urine  before  distillation,  as 
the  acetone  becomes  distilled  very  well 
without  acid  and  the  acid  might  disinte- 
grate other  substances  present  and  thus 
cause  the  formation  of  acetone.  There 
is  no  reason  why  special  care  should  be 
taken  lest  a  small  amount  of  ammonia  be 
distilled  with  the  acetone.  The  distilla- 
tion is  only  continued  until  a  sufficient 
quantity  of  fluid  for  the  different  tests 
to  be  employed  has  passed  over  into  the 
recipient.  The  distillation  is  then  sub- 
jected to  the  following  tests: — • 

Lieben's  Iodofoem  Test. — To  a  few 
cubic  centimetres  of  the  distillate  a  few 
drops  of  a  solution  of  potassium  and 
some  drops  of  a  solution  of  iodine  and 
iodide  of  potassium  are  added,  the  solu- 
tion of  potassium  being  added  in  excess. 
AVhen  acetone  is  present,  a  thick,  yellow 
precipitate  of  iodoform  will  immediately 
form.  This  test  will  reveal  0.01  milli- 
gramme. By  heating,  the  iodoform 
evaporates  and  accumulates  on  the  sides 
of  the  test-tube  in  the  form  of  small 
yellow  plaques,  consisting  of  the  charac- 
teristic crystals  of  iodoform.  The  most 
serious  objection  to  Lieben's  test  is  that 
many  (at  least  seventeen)  other  sub- 
stances, and  especially  alcohol,  may  give 
the  same  result. 

Lieben's  iodoform  test  recommended 
both  for  delicacy  and  ease  of  application. 
A  yellow  opacity,  with  precipitation  of 
iodoform,  occurs  if  acetone  be  present. 
Nothing  else  that  occurs  in  the  urine, 
except  acetone,  is  able  to  give  this  pre- 
cipitate of  iodoform,  without  warning. 
When  but  small  quantities  are  present 
the  urine  should  first  be  made  acid  with 
sulphuric  acid  and  distilled.  When  half 
the  urine  has  been  distilled  all  the  ace- 
tone has  been   found   to  be   in   the   dis- 


tillate.    Euttan    (Montreal    Med.   .Jour., 
Mar.,  '91). 

The  most  satisfactory  test  for  acetone 
in  the  urine  is  Lieben's.  It  is  performed 
by  adding  a  few  drops  of  Lugol's  solution 
to  the  first  10  cubic  centimetres  obtained 
by  distilling  400  cubic  centimetres  of 
fresh  urine,  then  adding  sodium-hydrox- 
ide solution  until  the  brown  color  disap- 
pears. In  the  presence  of  acetone  a  milky 
precipitate  of  iodoform  is  produced,  and 
may  be  recognized  by  its  violet  colora- 
tion with  caustic  soda  and  thymol,  or  by 
its  yellow  hexagonal  crystals  under  the 
microscope.  Ronsse  (Annales  de  Gyn.  et 
d'Obstet,  Mar.,  1900). 

Gunning's  Test. — Gunning  modified 
Lieben's  test  by  using  a  solution  of  am- 
monia and  tincture  of  iodine.  Le  Nobel 
prefers  to  use  a  solution  of  ammonia  and 
iodine  dissolved  in  iodide  of  ammonium; 
this  certainly  is  the  best  way  to  make  tlie 
iodoform  test,  as  no  alcohol  is  added  with 
the  reagents.  According  to  le  Nobel, 
0.001  milligramme  of  acetone  can  be  de- 
tected by  this  test,  but  von  Jaksch  could 
only  detect  acetone  by  it  when  present 
in  a  quantity  of  0.1  milligramme.  Errors 
caused  by  the  presence  of  alcohol  are 
avoided  by  this  test. 

Eetnold's  Test.  —  Freshly  precipi- 
tated oxide  of  mercury  is  dissolved  by 
acetone  in  the  presence  of  alkali.  Le 
Nobel  prefers  to  make  the  test  by  pre- 
cipitating a  solution  of  perchloride  of 
mercury  with  an  alcoholic  solution  of 
caustic  potash,  added  until  the  mixture 
gives  a  strong  alkaline  reaction;  then  the 
fluid  containing  acetone  is  added  and  the 
whole  well  shaken  in  a  test-tube.  The 
fluid  is  then  filtered  and  care  taken  that 
the  filtrate  be  perfectly  limpid.  The 
combination  of  acetone  and  oxide  of 
mercury  in  the  filtrate  can  be  detected  by 
chlorate  of  stannum  or  by  floating  some 
drops  of  the  filtrate  on  a  solution  of 
sulphide  of  ammonium:  where  the  two 
liquids  touch   each   other  a  black  ring 


84 


ACETONURIA.  TESTS  FOR  ACETONE. 


will  appear.  By  means  of  this  test  0.01 
milligramme  of  acetone  is  revealed,  and 
the  test  is  at  once  very  delicate  and  very 
reliable. 

The  Nitkoctanide  Test. — This  test 
is  made  with  the  distillate  quite  in  the 
same  manner  as  with  the  urine  either 
after  the  method  of  Legal  or  after  le 
Nobel's  modification  of  it.  This  test 
is  less  delicate,  and  the  phenols,  which 
possibly  might  have  passed  over  into  the 
distillate,  are  apt  to  give  the  same  color 
as  the  acetone;  the  test,  therefore,  gives 
no  proof  of  the  presence  of  the  latter 
substance. 

Penzoldt's  Indigo  Test.  —  Baeyer 
and  Drewsen  found  that  acetone  forms 
indigo  blue  with  orthonitrobenzaldehyde. 
Penzoldt  has  employed  this  reagent  by 
dissolving  urine  crystals  of  orthonitro- 
benzaldehyde in  boiling  water;  on  cool- 
ing down  the  aldehyde  forms  a  white, 
milky  cloud;  the  fluid  which  is  to  be 
tested  is  now  added  and  the  mixture 
rendered  alkaline  with  a  solution  of  pot- 
ash. When  acetone  is  present  a  yellow 
color  will  appear,  which  changes  to  green 
and,  after  ten  minutes,  to  indigo;  it  also 
forms  an  indigo-blue  precipitate.  Very 
small  quantities  of  acetone  may  be  de- 
tected by  shaking  the  mixtiire  with  a  few 
•drops  of  chloroform.  When  left  quiet 
ior  some  time  the  chloroform  takes  a 
blue  color  and  sinks  to  the  bottom  of  the 
test-tube. 

According  to  Penzoldt,  acetone  is  re- 
vealed by  this  test  in  a  solution  of  1  to 
2000.  According  to  von  Jaksch,  the 
smallest  quantity  of  acetone  revealed  by 
it  is  1.6  milligrammes.  Aldehyde  ace- 
tophenone  and  other  substances  form 
indigo  in  the  same  way  as  acetone,  but 
the  color  is  not  so  marked. 

Maleeba's  Test.  —  Malerba  found 
that  a  ^/o-per-cent.  solution  of  parami- 
dochmethylaniline  with  acetone  gives  a 


reddish  color,  changing  into  violet  and 
blue-red. 

The  violet  color  changes  to  rose  and 
the  next  day  to  red.    Under  the  spectro- 
scope two  stripes  are  seen  analogous  to 
those  of  haemoglobin.     The  test  is  also 
good  for  uric  acid^  the  solution  of  the 
latter  being  left  to  evaporate,  and  when 
the  residue  is  fairly  dried  some  drops  of 
the  above  solution  added,  when  a  blue 
coloration  is  obtained.     Malerba   (Eevue 
des  Sci.  Med.  en  France  et  a  I'Etranger, 
Apr.  25,  '95). 
Miscellaneous  Tests. — With  bisul- 
phite of  soda,  acetone,  as  well  as  the  alde- 
hydes, combines  to  a  crystallic  compound 
in  thin  flakes  resembling  much  those  of 
cholesterin,  even  by  microscopical  exam- 
ination.   (Limprieht.) 

Acetone  in  an  alkaline  solution  com- 
bines with  iodine  to  form  iodoform. 

Freshly  precipitated  oxide  of  mercury 
is  dissolved  by  acetone.  Indigo  is  formed 
when  acetone  is  combined  with  orthoni- 
trobenzaldehyde in  an  alkaline  solution. 
(Baeyer  and  Drewsen.) 

Bichloride  of  mercury  recommended  as 
a  reagent  for  acetone  and  albumin,  as 
well  as  for  the  estimation  of  the  quan- 
tity of  glucose  and  nitrogen  present  in 
the  urine.  Pittarelli  (GI'  Incurabili  Gior. 
di  Clin,  e  di  Terapia,  Nos.  16  and  17,  '94). 
Certain  substances  (sugars)  yield  the 
reactions  usually  characterizing  acetone. 
This  is  due  to  decomposition  of  sugar 
and  formation  of  aeetaldehyde.  In  test- 
ing by  the  ordinary  method,  the  urine 
should,  therefore,  be  moderately  acidified 
and  distilled  slowly  and  not  too  long. 
Salkowski  (Jour,  de  Med.,  de  Chir.,  et 
de  Phai-m.,  Bruxelles,  Jan.  26,  '95). 

From  what  has  just  been  stated  it  will 
become  apparent  that  none  of  the  tests 
are  specific  for  acetone  alone.  To  be 
quite  sure  that  acetone  is  contained  in 
the  distillate,  it  is,  therefore,  necessary 
to  try  successively  by  all  the  tests,  and 
only  when  all  tests  give  positive  result  is 
the  presence  of  acetone  proved. 

Von  Jaksch  has  tried  to  employ  the 


ACETONURIA. 


ACETO-ORTHO-TOLUIDE. 


85 


nitrocyanide  test  for  a  quantitative  esti- 
mation of  the  acfitone,  and  the  iodoform 
test  has  been  recommended  by  Messinger 
and  Huppert  for  the  same  purpose.  The 
quantity  of  iodine  used  to  form  iodoform 
with  the  acetone  is  measured,  and  the 
quantity  of  the  acetone  present  in  the 
solution  calculated  by  it  also;  but,  al- 
though Engel  and  Devoto  are  of  the 
opinion  that  it  is  possible  to  make  pretty 
accurate  estimations  in  this  way,  meth- 
ods for  quantitative  estimation  of  the 
acetone  are  not  to  be  relied  upon,  as  it 
is  impossible  to  avoid  errors  caused  by 
the  presence  of  substances  which  are  in- 
fluenced by  the  tests  in  the  same  way  as 
the  acetone. 

Diacetie  acid  (CJI.O,  =  CH3— CO— 
CH,— COOH)  may  be  revealed  in  the 
urine  by  the  aid  of  a  solution  of  per- 
chloride  of  iron,  which,  with  diacetie 
acid,  produces  a  dark,  wine-red  color. 
The  test  is  made  by  adding  a  soliition 
of  perchloride  of  iron  as  long  as  a  pre- 
cipitate of  phosphates  of  iron  is  formed. 
The  mixture  is  then  filtered  and  some 
drops  of  perchloride  are  added  to  the 
filtrate.  When  diacetie  acid  is  present, 
the  filtrate  takes  a  deep-red  color,  which 
vanishes  in  twenty-four  hours,  and  more 
rapidly  after  addition  of  strong  acids. 
Von  Jaksch  has,  by  a  colorimetric 
method  based  on  this  test,  tried  to  make 
an  approximate  estimation  of  the  quan- 
tity of  diacetie  acid  contained  in  the 
urine,  but  newly-passed  urine  can  alone 
be  used  for  the  search  of  diacetie  acid, 
as  this  acid,  after  some  time — twenty- 
four  to  forty-eight  hours — will  disappear 
from  the  urine.  Diacetie  acid  can  be 
isolated  from  the  urine  by  adding  a  few 
drops  of  sulphuric  acid  and  shaking  the 
mixture  with  ether.  When  diacetie  acid 
is  present,  it  is  dissolved  in  the  ether 
and  can  be  detected  by  the  perchloride- 
of-iron  test. 


Beta-oxybutyric  acid  (C4ris03)  is  also 
found  sometimes  in  the  urine  of  fever 
patients,  as  well  as  in  diabetes,  with  ace- 
tone and  diacetie  acid.  This  may  also 
be  the  case  in  the  dyspepsia  of  alcohol- 
ism and  in  carcinoma  of  the  stomach. 
When  beta-oxybutyric  acid  is  cautiously 
oxidated,  acetone  is  found. 

F.  Letison, 

Copenhagen. 

ACETO-ORTHO-TOLTJIDE.  —  Aceto- 
ortho-toluide  is  an  isomer  of  exalgin, 
and  appears  in  the  form  of  colorless 
needles,  freely  soluble  in  alcohol,  ether, 
and  hot  water,  but  little  soluble  in  cold 
water.  Its  melting-point  is  224.6°  F. 
and  boiling-point  564.8°  F.,  being  com- 
parable in  these  respects  to  acetanilid 
and  methylacetanilid,  which  it  resembles 
chemically,  being  also,  like  these  drugs, 
an  active  antipyretic. 

Physiological  Action.  —  Aceto-ortho- 
toluide  acts  chiefly  on  the  cord,  and  only 
in  toxic  doses  on  the  brain  and  medulla. 
The  heart  is  last  affected.  Doses  of  V» 
grain  per  kilogramme  of  the  body-weight 
reduce  normal  temperature  by  about 
1  V2°  F.,  and  bring  febrile  temperatures 
to  the  normal  point.  It  does  not  alter  the 
blood-pressure,  but  somewhat  increases 
the  frequency  of  the  heart-beats,  though 
leaving  the  vasomotor  centres  unaffected. 
It  causes  dilatation  of  the  blood-vessels 
by  direct  stimulation  of  the  nervous  ele- 
ments of  the  vascular  walls  themselves. 
The  fall  of  temperature  is,  moreover,  due 
to  the  loss  of  heat  consequent  on  this 
dilatation.     (Barabini.) 

Therapeutics. — Although  this  product 
was  introduced  as  one  superior  to  ace- 
tanilid, owing  to  its  being  less  toxic,  it 
does  not  seem  to  have  received  much 
support  from  the  profession.  It  was  also 
credited  with  antiseptic  properties  even 
in  a  weak  solution  (5  to  1000). 


ACETYLENE.    POISONING. 


ACETYLENE.— When  calcium  carbide 
(CaCo)  is  brought  in  contact  with  water, 
acetylene-gas  is  formed.  Being  capable, 
when  lighted,  of  furnishing  a  degree  of 
light  far  superior  to  that  of  ordinary  gas, 
acetylene  has  recently  been  considerably 
used  as  an  illuminant.  When  prepared 
from  pure  calcium  carbide  and  purified 
by  liquefaction,  it  has  a  pleasant  ethereal 
odor  and  can  be  breathed  in  small  quan- 
tities without  giving  rise  to  ill  effects. 
Impure  gas,  prepared  from  coal  or  im- 
pure lime,  may  contain  calcium  sulphide 
and  phosphide,  and  the  acetylene  pre- 
pared from  it  may  then  have  a  very 
unpleasant  odor. 

Acetylene  Poisoning. — Acetylene  may 
be  fatally  poisonous  when  present  in 
proportions  as  high  as  40  per  cent,  by 
volume,  as  recently  shown  by  G-rehant, 
Berthelot,  and  Moissant.  A  mixture  of 
20  volumes  of  acetylene — prepared  from 
calcium  carbide,  20.8  volumes  of  oxy- 
gen, and  59.2  volumes  of  nitrogen — was 
breathed  by  a  dog  for  thirty-five  minutes 
without  any  marked  disturbance,  and 
100  cubic  centimetres  of  the  blood  were 
found  to  contain  10  cubic  centimetres 
of  acetylene.  With  40  volumes  of  acety- 
lene, the  proportion  of  oxygen  remain- 
ing the  same,  a  dog  died  in  less  than  an 
hour,  owing  to  failure  of  the  heart's 
action,  and  100  cubic  centimetres  of 
blood  contained  20  cubic  centimetres  of 
acetylene.  With  79  volumes  of  acety- 
lene and  21  volumes  of  oxygen  the  poi- 
sonous effects  were  still  more  strongly 
marked. 

The  poisonous  action  of  acetylene  it- 
self is  feeble  when  the  blood  is  at  the 
same  time  supplied  from  the  air  with 
the  usual  amount  of  oxygen.  In  other 
words,  acetylene  inhaled  in  the  open  air 
is  but  slightly  harmful. 

One  hundred  volumes  of  blood  dissolve 
about  eighty  volumes  of  acetylene;    the 


solution    shows    no    characteristic    spec- 
trum, and  is  reduced  by  ammonium  sul- 
phide   as    readily    as    ordinary    arterial 
blood.     In  a  vacuum  part  of  the  acety- 
lene is  evolved  at  the  ordinary  tempera- 
ture and  part  at  60°  F.     If  the  blood  is 
allowed  to  putrefy,  the  volume  of  acety- 
lene given  off  at  the  ordinary  tempera- 
ture remains  practically  the   same,   but 
the  quantity  liberated  at  60°   decreases 
as  putrefaction  advances.     If  any  com- 
pound  of   acetylene  and  hEemoglobin  is 
formed,  it  is  very  unstable,  and  is  not 
analogous  to  earboxyhasmoglobin.     Bro- 
ciner  (Boston  Med.  and  Surg.  Jour.,  July 
30,  '96). 
In  a  closed  room,  however,  where  the 
oxygen  is  not  kept  up  to  the  normal 
standard,  when  the  accumulation  of  a 
foreign  gas  would  prevent  the  constant 
renewal  of  air  through  window  and  door 
interstices  or  open  chimneys,  and  where 
the    products    of   respiration   would    be 
allowed  to  accumulate,  it  would  quickly 
prove  mortal  by  paralyzing  the  respira- 
tory function. 

Experiments  on  dogs,  guinea-pigs,  and 
other  animals  showing  that  acetylene  has 
considerable  toxic  power.  One  pint  of 
the  pure  gas  caused  severe  symptoms  of 
poisoning  in  dogs,  and  even  when  mixed 
with  air  (20  per  cent.)  it  proved  fatal 
after  an  hour.  If  the  gas  was  adminis- 
tered rapidly,  the  animals  recovered 
when  placed  in  the  open  air,  but  if  given 
slowly  this  did  not  occur,  and  the  ani- 
mals died.  Mosso  and  Ottolenghi  (Rif. 
Med.,  Jan.  23,  '97). 

A  mixture  of  air  and  acetylene  com- 
mences to  be  explosive  when  it  contains 
5  per  cent,  of  acetylene,  whereas  it  re- 
quires the  presence  of  8  per  cent,  of  coal- 
gas  to  make  a  similar  mixture  explosible. 
If  a  rabbit  is  placed  in  a  bell-jar  into 
Avhich  ordinary  air  and  acetylene  are 
pumped,  the  animal  seems  for  a  long 
period  to  experience  very  little  incon- 
venience. It  is  not  until  ordinary  at- 
mospheric air  is  excluded  and  only  acety- 
lene admitted  that  symptoms  gradually 
and  slowly  develop.  After  a  more  length- 
ened exposure  to  acetylene  than  that 
which  is  necessary  for  coal-gas  the  ani- 


ACETYLENE. 


mal  becomes  intoxicated,  it  falls  over  on 
its  side  apparently  profoundly  asleep, 
and,  while  all  through  the  experiment  its 
breathing  has  been  somewhat  short  and 
rapid,  stupor  steals  over  the  animal  ap- 
parently painlessly.  A  few  inhalations 
of  atmospheric  air  are  sufficient  to  re- 
store to  the  animal  all  its  faculties. 
Should  inhalation  have  been  pushed  fur- 
ther and  the  animal  have  been  very 
deeply  asphyxiated,  death  may  ensue, 
cyanosis,  hitherto  observed,  being  rapidly 
replaced  by  extreme  pallor.  In  minor  and 
easily-recoverable  stages  of  asphyxia  the 
vascular  tension  is  still  maintained,  and 
there  is  no  difficulty  in  obtaining  a  drop 
of  blood  for  examination;  but  when  the 
deeper  stages  are  reached  so  extremely 
contracted  are  all  vessels  that  it  is  al- 
most impossible  to  obtain  even  a  trace 
of  blood.  When  this  stage  has  been 
reached  recovery  is  difficult.  When  blood 
of  a  rabbit  was  examined  at  different 
stages  of  intoxication  from  acetylene, 
and  especially  in  deepest  asphyxia,  this 
fluid  on  spectroscopic  examination  al- 
ways exhibited  two  well-marked  bands 
of  oxyhsemoglobin;  also  that,  unlike  the 
blood  in  coal-gas  poisoning,  although  re- 
sembling it  in  the  cheriy-red  color  which 
it  presented^  it  was  readily  reduced  on 
the  application  of  ammonium  sulphide 
and  gentle  heat.  Thomas  Oliver  (Brit. 
Med.  .Jour.,  Apr.  23,  '98). 

It  has  been  said  that  acetylene  is  very 
poisonous;  the  experiments  of  many  ob- 
servers, and  especially  those  of  Grehant, 
do  not  confirm  this  statement.  He 
proved  that  acetylene  simply  dissolves  in 
the  blood-plasma,  while  carbon  monoxide 
forms  a  compound  with  the  hoemoglobin 
of  the  blood.  Acetylene,  while  slightly 
poisonous,  is  less  poisonous  than  coal-gas, 
and  vastly  less  than  water-gas,  which 
contains  a  high  percentage  of  carbon 
monoxide.  E.  Renouf  {Pharm.  Era,  July 
20, '99). 

Treatment  of  Acetylene  Poisoning.  — 
That  fresh  air  should  at  once  be  given 
the  patient  need  hardly  he  mentioned. 
The  patient  should  be  removed  from  the 
poisoned  atmosphere  into  a  well-venti- 
lated room  and  artificial  respiration  prac- 


ticed. Hypodermic  injections  of  strych- 
nia and  digitalis  should  be  administered, 
while  oxygen  is  sent  for.  This  gas  should 
be  inhaled  as  soon  as  practicable,  while 
artificial  respiration  is  continued  with 
vigor,  the  patient  being  simultaneously 
rubbed.  Eectal  injection,  of  warm  coffee 
are  also  useful. 

In  all  such  cases  the  efforts  of  the  phy- 
sician should  be  kept  up  a  long  time,  the 
sespiration  and  pulse  being  unreliable 
guides  as  regards  the  presence  in  the 
system  of  sufficient  life  to  render  re- 
suscitation possible. 

Therapeutics. — Acetylene  has  not  been 
used  in  therapeutics. 

ACNE. 

Definition.  —  Acne  is  characterized  by 
the  presence,  on  the  face,  of  small  eleva- 
tions or  nodosities  varying  in  size  from 
a  pin-head  to  a  pea.  These  elevations,  or 
pimples,  are  also  present  on  the  back, 
shoulders,  and  chest  in  many  cases. 

Symptoms.  —  The  elevations  are  con- 
ical or  hemispherical,  and,  as  a  rule,  in 
the  earliest  stage  of  the  lesion  somewhat 
painful,  especially  upon  pressure.  In 
most  of  the  lesions  there  is  a  distinct 
tendency  to  suppurative  change.  In  the 
centre  of  the  lesion  a  whitish-yellow  spot 
forms  where  the  pus  raises  the  epidermis. 
In  from  three  to  ten  days,  or  even  longer, 
the  lesion  breaks  and  a  small  amount 
of  pus  is  discharged.  At  other  times 
the  pus  dries  to  a  thin  crust,  or  occasion- 
ally the  contents,  especially  in  sluggish 
lesions,  are  absorbed.  A  red  elevation  is 
left  which  gradually  flattens  out,  leav- 
ing a  brownish  stain,  which  eventually 
disappears.  The  surrounding  skin  is  fre- 
quently oily  and  shiny.  Tumors  as  large 
as  a  pea  or  a  small  nut,  formed  by  re- 
tention-cysts of  sebaceous  glands,  are 
sometimes  seen;  they  may  graduallv 
work  to  the  surface  or  may  persist  lor 


ACNE.    VARIETIES. 


months  and  finally  disappear  or  form 
hard  spherical  indurations  by  retraction 
and  inspissation  of  their  contents.  Scar- 
ring, usually  consisting  of  small,  white, 
cicatricial  depressions,  is  to  be  seen  as 
a  consequence  in  some  cases.  In  the 
majority  of  cases,  however,  permanent 
marks  are  not  left.  The  regions  most 
affected  in  acne  are  the  face,  shoulders, 
and  anterior  and  posterior  aspects  of  the 
shoulders.  Occasional  cases  are  observed 
in  which  the  back,  extending  as  far  down 
as  the  sacrum,  is  the  chief  seat  of  the 
disease.  In  rare  instances  (acne  cachec- 
ticorum,  acne  scrofulosorum,  and  acne 
medicamentosa)  the  eruption  may  be 
more  or  less  general. 

Varieties. — There  are  several  varieties 
of  lesion  observed  in  acne,  one  kind  of 
which  is  apt  to  predominate,  and  this 
has  given  rise  to  the  so-called  varieties 
of  the  disease. 

Acne  vulgaris,  or  acne  simplex,  is,  by 
'  far,  the  most  common  clinical  type.  The 
lesions  are  usually  of  a  mixed  character, 
consisting  of  black-heads,  pin-head  to 
pea-  sized  papules,  papule-pustules,  and 
pustules.  Each  lesion  may  in  its  begin- 
ning have  a  small,  red  areola.  There 
is  also  slight  pain  upon  pressure.  The 
lesions  are  rapid  in  evolution,  running  a 
course  in  several  days  to  a  week.  As  in 
all  types,  they  are  discrete  and  isolated. 

The  term  "acne  papulosa"  is  given  to 
a  not  uncommon  type  in  which  the 
lesions  are  usually  small  and  show  but 
little  disposition  to  reach  the  pustular 
stage,  disappearing  by  absorption  or  by 
desiccation  and  exfoliation. 

Acne  punctata  might  be  termed  mi- 
nute papular,  the  lesions  being,  for  the 
most,  pin-head  in  size,  with  a  central 
comedo,  or  black-head. 

Acne  pustulosa  is  another  type  in 
which  the  lesions  go  rapidly  into  the 
pustular  stage,  the  eruption  appearing. 


for  the  most  part,  to  be  made  up,  almost 
entirely,  of  pustules.  In  size  they  vary 
from  a  large  pin-head  to  a  large-sized 
pea.  "Acne  indurata,"  or  "tuberculosa," 
is  a  form  of  the  eruption  in  which  the 
lesions  tend  to  be  closely  crowded  here 
and  there  and  in  such  places,  and  also 
with  single  lesions,  the  underlying  base 
becomes  hard,  inflamed,  and  indurated, 
being  also  somewhat  deep-seated. 

In  acne  phlegmonosa  the  inflamma- 
tory and  suppurative  process  begins  deep 
down  in  the  sebaceous  gland,  forming 
veritable  small  dermic  and  intradermic 
abscesses,  usually  with  but  slight  tend- 
ency to  break  through  the  surface. 

Acne  cachecticorum  characterizes  an 
acneic  eruption,  more  or  less  general, 
occurring  in  weak,  cachectic  individuals; 
the  lesions  are  livid,  indolent,  violet-red 
papulo-pustules  of  moderate  and  large 
size  and  of  slow  evolution,  leaving,  as 
a  rule,  small  cicatrices.  Acne  scrofulo- 
sorum is  really  a  variety  of  the  last 
named,  —  acne  cachecticorum,  —  occur- 
ring in  those  of  distinctly  strumous  or 
tuberculous  temperament. 

Severe  case  of  acne  scrofulosorum  in 
girl  with  no  tubercular  family  history, 
but  with  enlarged  cervical  glands.  Ac- 
neic pustules  and  comedones  extremely 
numerous,  developed  in  crops,  suppurated 
freely,  left  deep  livid-blue  scars,  most 
noticeable  over  buttocks  and  thighs. 
J.  J.  Pringle  (Brit.  Jour,  of  Derm.,  Apr., 
'95). 

Five  cases  of  acne  scrofulosorum  in 
infants.  Clinical  features:  an  indolent, 
small  papulo-pustular  or  acneiform  erup- 
tion, occurring  in  infants,  sparsely  dis- 
seminated and  not  grouped,  unaccom- 
panied by  subjective  symptoms.  It 
aflfects  chiefly  the  extremities,  the  lower 
in  particular,  and  their  extensor  sur- 
faces. The  buttocks  and  regions  above 
are  often  involved.  The  lesions  appear 
successively  or  by  subacute  outbreaks. 
The  papules  develop  about  the  hair- 
follicles   and   become    successively   pust- 


ACNE.     VARIETIES.     ETIOLOGY. 


89 


ular  and  crusted.  When  the  crust  with 
a  central  plug  is  lost,  a  flattened,  cra- 
teritorm,  irregular  lesion,  like  those  of 
lichen  planus,  is  left.  After  complete 
involution,  a  stain  or  faint  scar  remains. 
T.  Colcott  Fox  (Brit.  Jour,  of  Derm.,  vol. 
vii.  No.  11,  p.  341,  '95). 

Acne  artificialis  sen  medicamentosa  is 
a  form  of  acneie  eruption  produced  by 
the  ingestion  of  certain  drugs,  as  the 
iodides  and  bromides,  and  also  by  the 
external  applications  of  certain  remedies, 
such  as  tar,  the  paraffin-oils,  etc. 

An  artificial  type  of  acne  may  be  seen 
on   the   ehestj   abdomen,   and   back,   the 
cheeks,  forehead,  and  chin  being  affected 
in   those   who   are  taking   iodide,   while 
the  chin   is   covered   when  the   cause  is 
either  menstrual  or  intestinal.    That  as- 
sociated with  rosacea  begins  around  the 
nose.     In  the  cachectic  type  or  in  those 
who  are  hard  students  or  of  a  nervous 
temperament  it  is  more  frequently  wit- 
nessed   on    the    forehead.      Those    who 
present  lesions  upon  the  entire  face  are 
generally  found  to  suffer  from  habitual 
constipation.     The  treatment  should  be 
based    upon    these    facts.      Dyer     (New 
Orleans  Med.  and  Surg.  Jour.,  June,  '94) . 
"Acne  atrophica"  is  a  name  given  to 
those  cases  of  acneie  eruption  which  tend 
to  leave  depressed  scars.    This  probably 
occurs  most  frequently  in  those  cases  in 
which  the  lesions  are  sluggishly  papular 
or  papulo-pustular,  the  lesions  disappear- 
ing by  absorption  or  crusting  and  leaving 
behind  small  punched-out  cicatrices. 

Acne  hypertrophica  is  really  the  op- 
posite of  the  last-named  variety,  and 
occurring  in  about  the  same  kind  of 
cases,  small,  whitish,  connective-tissue 
pin-point  or  small-pea  sized  projecting 
hypertrophies  marking  the  sites  of  the 
lesions.    It  is  rare. 

Etiology.  —  Acne  begins  usually  near 
puberty,  when  the  pilar  system  is  more 
actively  developing,  and  the  functions 
of  the  sebaceous  glands  likewise;  and  is 
more  frequent  among  patients  with  di- 


gestive troubles,  constipation,  dilatation 
of  the  stomach,  menstrual  irregularities, 
the  strumous  diathesis,  possibly  the  ar- 
thritic diathesis,  and  disturbances  of  the 
nervous  system. 

Anaemia,  dyspepsia,  constipation,  amen- 
orrhoea,  and  dysmenorrhoea  are  all  ex- 
ceedingly common  functional  derange- 
ments or  disorders  occurring  simulta- 
neously with  acne,  but  no  more  a  cause 
of  it  than  of  psoriasis  and  scabies. 
Stephen  Mackenzie  (Brit.  Jour,  of  Derm., 
Oct.,  '94). 

Constipation  is  a  most  important  fac- 
tor. That  nerve-influence  considerably 
affects  acne  may  be  witnessed  during 
menstruation  and  dyspepsia.  Stopford 
Taylor   (Brit.  Med.  Jour.,  Oct.,  '94). 

It  has  been  also  alleged  that  lesions 
of  the  genito-urinary  organs  and  vene- 
real excesses  may  provoke  the  disease. 
Lesions  may  be  due  to  mechanical  irri- 
tation caused  by  the  product  of  secre- 
tion remaining  in  the  excretory  canal 
or  gland  itself.  Some  drugs,  as  already 
stated,  —  such  as  the  bromides  and 
iodides,  —  are  occasionally  responsible 
for  the  eruption  or  an  increase  in  an 
already  existing  eruption.  Certain  drugs 
applied  externally  may  also  provoke 
acneie  lesions,  such  as  tar  and  tar  prod- 
ucts, juniper-oil,  and  the  like.  Workers 
in  paraffin  and  paraffin  products  will 
not  infrequently  be  found  affected  with 
papules  and  pustules,  especially  those  of 
a  furuncular  or  abscess  type. 

Professional  form  peculiar  to  workers 
in  paraffin;  eruption  papular,  furuncu- 
lous,  or  acneiform;  affects  hairy  portions 
of  the  skin.  Gervais  (These  de  Paris, 
'95). 

[As  in  artificial  eruptions,  individual 
predisposition  here  naturally  plays  a 
most  important  rSle.  L.  Brocq,  Assoc. 
Ed.,  Annual,  '96.] 

Stubborn  indurated  and  pustular  acne 
witnessed  in  persons  exposed  to  chlorine- 
vapor.  The  condition  is  analogous  to 
iodine  and  bromine  acne.     Treatment  is 


90 


ACNE.     PATHOLOGY.     DIAGNOSIS.     TREATMENT. 


very  unsatisfactory.  Herxheimer  (Miinch. 
med.  Woch.,  Feb.  28,  '99). 
Pathology. — In  most  cases  the  process 
begins  by  a  perifolliculitis,  which  later 
on  gives  rise  to  a  purulent  folliculitis. 
It  would  thus  seem  that  the  sebaceous 
glands  play  but  a  small  part  in  the  af- 
fection. In  some  cases,  however,  when 
comedones  are  present,  the  sebaceous 
gland  itself  is  the  starting-point  of  the 
inflammatory  process.     (Brocq.) 

Even  when  the  foctis  of  irritation  is 
in  the  follicle,  it  is  frequently  limited  to 
the  sebaceous  or  sebaceous  pilary  canal. 
(E.  Besnier,  A.  Doyon.) 

The  papillse  surrounding  the  come- 
done  and  the  superficial  layers  of  the 
corium  are  filled  with  blood-vessels  full 
to  repletion,  and  of  exudation  cells  which 
are  found  in  dilated  vacuoles.  (Kaposi.) 
If  the  process  is  very  intense,  the  seba- 
ceous gland  may  be  entirely  destroyed  by 
the  local  inflammatory  action,  while  the 
pilar  bulba  persists.    (Kaposi.) 

The  acneic  process  may  be  divided  into 
two  parts:  1.  Closure  of  the  sebaceous 
follicle  and  formation  of  comedo.  2. 
Suppuration,  which  only  occurs  in  those 
follicles  where  the  staphylococci  aureus 
et  albus  have  penetrated  before  the 
comedo  formed.     (Unna.) 

In  true  acne  the  bacillus  described  by 
Unna  is  invariably  present.  It  always 
occupies  the  same  portion  of  the  com- 
edo,— namely,  the  bottom  of  the  central 
cavity,  only  reaching  the  uppermost  part 
in  markedly  developed  comedones.  Mena- 
hem  Hodara  (Jour,  des  Mai.  Cut.  et 
Syph.,  Sept.,  '94). 

Acne  is  a  local  disease  whose  anatom- 
ical element  is  the  sebaceous  gland,  the 
physiological  element  being  the  over- 
secretion  of  fat,  while  probably  there  is 
a  third  bacteriological  element.  Malcolm 
Morris  (Brit.  Jour,  of  Derm.,  Oct.,  '94). 

Acne  is  due  to  an  epithelial  secretion 
of  fat  beyond  what  could  be  consumed 
by  the  integument:  a  deposit  of  unusual 
fat  collected  in  the  ducts  of  the  glands. 


giving  rise  to  microbic  changes.  Leslie 
Roberts  (Brit.  Jour,  of  Derm.,  Oct.,  '94). 
Bacteriological  examination  of  come- 
dones and  pustules:  The  staphylococcus 
pyogenes  albus  is  constantly  present  in 
the  pustules  of  acne;  there  are  also 
present  occasionally  a  yeast-fungus  and 
a  bacillus,  but  always  in  small  numbers. 
In  the  non-inflamed  comedo  there  is  an 
abundant  development  of  microbes,  the 
staphylococcus  albus  always  being  pres- 
ent. At  the  moment  that  inflammation 
occurs  in  the  comedo  a  considerable 
diminution  in  the  number  of  kinds  of 
microbes  occurs. 

The  skin  of  those  not  aflfected  by  acne 
is  just  as  rich  in  microbic  species  as  that 
of  the  acneic  patient. 

The  presence  of  certain  microbes  is  not 
sufficient  to  explain  the  occurrence  of  the 
malady.  One  cannot  accept  the  theory 
of  a  specific  cause  in  acne. 

Unna's  special  bacillus  is  only  a  small 
virulent  variety  of  the  bacterium  coli. 
Lomry  (Derm.  Zeit.,  B.  3,  H.  4,  '96). 

In  all  cases  a  high  specific  gravity  of 
the  urine  and  an  increase  of  the  crystal- 
line sediments  noted.    The  increase  of  the 
salts  in  the  blood  causes  an  irritation  in 
the  sebaceous  glands  or  in  their  vessels. 
Bardach  (Derm.  Zeit.,  vol.  ii.  No.  2,  '96). 
Diagnosis.  —  Acne  is  to  be  differenti- 
ated from  the  papular,  papulo-pustular, 
and  pustular  syphiloderms,  and  also  from 
variola. 

Syphilis. — In  the  syphilitic  eruption 
the  distribution  is  more  or  less  general, 
and  more  acute  in  its  outbreak,  darker 
hued,  and  occurring  occasionally  with 
special  groupings  and  the  presence  of 
other  symptoms  of  the  disease. 

Vaeiola. — In  small-pox  the  premoni- 
tory constitutional  symptoms,  the  sudden 
outbreak,  the  uniformity  of  the  lesions, 
and  many  other  symptoms  of  differential 
character  will  serve  to  differentiate. 

Treatment. — In  this  connection  acne 
may  be  divided  into  (1)  an  irritable  or 
inflammatory  variety,  in  which  the  skin 
is  fine  and  thin  and  easily  irritated  by 
stimulating  applications,  and  where  gen- 


ACNE.     TREATMENT. 


91 


eral  treatment  is  important  on  account 
of  the  close  union  between  the  acneic 
eruption  and  various  constitutional  dis- 
turbances. Local  treatment  should,  at 
first  at  least,  be  of  a  mild  character.  (2) 
An  indolent  variety,  where  the  integu- 
ment is  thick,  rough,  and  oily,  with  en- 
larged and  obstructed  gland-orifices,  and 
where  the  most  energetic  local  applica- 
tions are  well  borne;  here  the  local  treat- 
ment is  important.  Probably  most  of 
the  cases  met  with  occupy  a  middle 
ground  between  these  two  extreme  vari- 
eties. 

Geneeal  Teeatment. — Prophylactic 
measures,  such  as  the  avoidance  of  ex- 
ternal irritants,  drugs  and  food  liable  to 
cause  acne,  such  as  coffee,  tea,  alcohol, 
pure  wine,  pork,  veal,  game  too  far  gone, 
preserved  fish,  shell-fish,  fats,  and  cheeses. 
Increase    in    the    solids    of    tlie    blood 
causes    an    irritation    of    tlie    sebaceous 
glands.     Rapid  cure  is  effected  in  these 
cases    by    increasing    diuresis    and    local 
applications  of  a  soap  containing  about 
1  Vi  per  cent,  of  iodate  and  bromate  of 
sodium.      Bardach    (Derm.    Zeit.,   vol.   ii, 
No.  2,  '96). 

Any  disorder  of  digestion  must  be 
counteracted  in  order  to  avoid  the  con- 
gestion of  the  face  following  meals. 

Attention  to  the  condition  of  the  ali- 
mentary canal  and  other  disorders,  as 
well  as  well-directed  local  treatment,  is 
a  quicker  and  more  efficacious  method 
than  local  treatment  only.  Eadcliffe 
Crocker  (Brit.  Jour,  of  Derm.,  Oct.,  '94). 
Acne  can  be  cured  with  certainty  and 
in  a  comparatively  sliort  time.  The  ma- 
jority of  cases  are  benefited  by  the  tonic 
and  aperient  iron  and  magnesia  mixture 
between  meals,  others  by  an  alkaline  bis- 
muth mixture  before  food.  In  all  cases 
an  ointment  which  contains  30  grains  of 
sulphur,  10  grains  of  ammoniated  mer- 
cury, 10  grains  of  sulphide  of  mercury, 
and  an  ounce  of  vaselin  should  be  used, 
oxide  of  zinc  being  added  if  there  is  much 
inflammation.  Before  its  application  the 
patient  should  bathe  the  face  with  hot 


water   and   a    10-per-cent.   ichthyol  soap 

well  lathered  on.     An  important  part  of 

the  treatment  is  the  careful  application 

to  each  pimple  of  a  minute  drop  of  pure 

carbolic  acid,  just  liquefied  with  a  little 

water.    P.  S.  Abraham  (Lancet,  Sept.  22, 

1900). 

If  the  tongue   is   much   coateS   and 

shows  prominent  papillae,  the  following 

is  recommended: — 

1^   Sodium  bicarb.,  10  grains. 

Ext.  of  cascara  sagr.  liq.,  10  to  20 

minims. 
Tinct.    of   nux    vomica,    7    to    10 

minims. 
Peppermint-water,  enough  to  make 
1  fluidounee. — M. 

After  this  has  been  taken  for  a  week 
or  ten  days,  if*  there  is  any  indication 
for  iron,  a  pill  of  reduced  iron  of  2  or  3 
grains  may  be  given  after  dinner  or 
oftener. 

Constipation  should  be  counteracted 
by  gentle  aperients.  Any  condition 
capable  of  maintaining  the  sympathetic 
system  in  a  state  of  tension — such  as 
genito-urinary  trotibles  or  affections  of 
the  nasal  fosste — should  be  eradicated 
if  possible. 

If  the  patient  is  lymphatic  and  has  a 
good  digestion,  codliver-oil  is  of  value. 

Much  benefit  obtained  from  syrup  of 
laetophosphate  of  calcium  in  acne,  espe- 
cially when  lumps  are  large.    A  favorable 
and  palatable  mixture  when  codliver-oil 
is  required  is  the  following:  — 
B  Gum  arabic,  10  drachms. 
Water,  1  ounce. 
Syrup  of  laetophosphate  of  calcium, 

3  ounces. 
Codliver-oil,  4  ounces. 
Essential   oil   of   bitter   almonds,   3 
minims. 
The  gum,  water,  and  syrup  sliould  be 
rubbed  together  until  a  smooth  mucilage 
is  made,   then  the   codliver-oil  is  to  be 
added  gradually,  with  constant  stirring, 
and    last     the     essential     oil     of    bitter 
almonds.     Made  in  this  way,  each  table- 


92 


ACNE.     TREATMENT. 


spoonful  of  the  mixture  contains  4  grains 
of  lactophosphate  of  calcium  and  50  per 
cent,  of  codliver-oil.    H.  S.  Purdon  (Dub- 
lin Jour,  of  Med.  Sei.,  Feb.,  '98). 
Anaemia  or  chlorosis  call  for  the  use 
of  chalybeates  with  arsenic.     Iron  often 
does  harm  unless  its  constipating  effect  is 
counteracted  by  using  aperients.    When 
the  patient  is  arthritic,  alkalies,   espe- 
cially alkaline  waters,  are  indicated. 

No  really  specific  treatment  is  known 
against  acne,  but  the  following  have  been 
recommended : — 

Sulphur  alone:    powder  or  tablets,  or 
with  equal  parts  of  honey. 
Ichthyol  (Unna): — 
1^   Ichthyol,  1  to  2  drachms. 

Dist.  water,  5  drachms. 
M.  Sig.:  Fifteen  to  fifty  drops  in 
water,  to  be  taken  morning  and  evening. 
Ichthyol  is  very  beneficial,  both  in 
acne  vulgaris  and  acne  rosacea.  The 
best  results  are  obtained  when  external 
and  internal  treatments  are  combined. 
In  some  cases  of  acne  rosacea  in  which 
the  skin  is  too  thin  and  irritable  to 
bear  even  weak  solutions,  the  internal 
administration  of  ichthyol  alone,  with 
steaming,  will  be  beneficial.  Five  grains 
of  ichthyol  may  be  given  thrice  daily 
after  food,  increasing  the  amount  to 
10  grains.  Every  night  and  morning  the 
face  is  steamed  for  fifteen  minutes,  and 
is  then  washed  with  ichthyol  soap. 
The  lather  is  allowed  to  dry  on  the  face, 
after  which  it  is  gently  washed  off  with 
Avater.  After  each  washing  ichthyol 
salve,  if  it  can  be  borne  (often  com- 
bined with  ammoniated  mercury),  is 
applied.  In  acne  vulgaris,  after  steam- 
ing, strong  sulphur  and  ichthyol  soap 
is  used,  with  brisk  rubbing  with  a  flesh- 
glove.  Brownlie  (New  York  Lancet, 
May,  1901). 

Arsenic  bromide  in  weak  doses,  ^/eo 
grain,  in  acne  pustulosa.     (Pifl'ard.) 

Mercurial  preparations,  such  as  cor- 
rosive sublimate  or  calomel,  either  alone 
or  with  jalap  or  colocynth  extract,  have 
been  found  useful. 


Ergotine, — alone  or  with  calcium  sul- 
phide,— digitalis,  belladonna,  hamamelis, 
and  quinine  have  been  recommended  by 
Brocq.  In  stubborn  cases  iodide  of  potas- 
sium has  been  found  eificacious. 

In  stubborn  cases  iodide  of  potash  in 
5-grain  doses  three  times  a  day  in  milk 
recommended.  When  a  moderate  iodism, 
showing  itself  in  urticarial  lesions  is  pro- 
duced and  when  the  urine  gives  traces  of 
iodine,  the  iodine  medication  should  be 
discontinued,  and  local  treatment  substi- 
tuted. Leviseur  (Med.  Record,  Nov.  11, 
'99). 

Potassium  iodide  in  doses  of  5  grains, 
three    times    daily,     recommended.      It 
should  be  discontinued  when  local  reac- 
tion occurs  or  iodine  appears  in  the  urine. 
When  inflammation  subsides,  the  treat- 
ment should  be  repeated.     Ichthyol  soap 
and  sulphur  ointment  are  to  be  applied  in 
the  intervals.    J.  Galloway  (Practitioner, 
May,  1900). 
Local  Teeatment.  —  Constitutional 
treatment  will  rarely  succeed  alone,  while 
in  a  large  proportion  a  local  treatment 
by  itself  will  be  found  eSicacious. 

In  the  prevention  of  aene  in  persons 
predisposed  to  the  disease  three  things 
especially  are  to  be  done:  1.  Remove 
superfluous  sebum  and  epithelial  accu- 
mulations in  the  ducts  of  the  glands. 
2.  Stimulate  the  sebaceous  glands  into 
healthy  activity.  3.  Keep  the  skin  asep- 
tic, so  as  to  prevent  the  pus-cocci  from 
gaining  admission  to  the  follicles.  The 
soaps  with  an  alkaline  basis  are  the  most 
efficient  as  they  are  the  most  powerful. 
The  most  useful  soaps  are  the  sulphur, 
campho-sulphur,  Peruvian-balsam,  and 
creolin  cake  soaps;  while,  of  the  pow- 
dered soaps,  the  alkaline,  brimstone,  and 
creolin,  and  the  neutral  salicylic-acid- 
sulphur,  and  salicylic-acid-resorcin-sul- 
phur  soaps  are  the  best. 

AVhen  the  disease  is  developed  all 
comedones  should  be  expressed  and  all 
pustules  opened.  Stimulating  soaps  or 
applications,  or  both,  should  then  be 
used.  Sulphur  is  the  most  important 
constituent  of  both.  When  there  is  very 
much  inflammation  around  the  acneic 
lesions  soothing  treatment  is  necessary. 


ACNE.     TREATMENT. 


93 


especially  at  first,  while  zinc  oxide  and 
calamin  lotion  and  belladonna,  locally 
applied,  are  sometimes  of  much  service. 
When  the  more  active  lesions  are  reme- 
died the  preventive  treatment  comes  into 
play,  and  it  must  be  impressed  on  the 
patients  that,  unless  they  are  willing  to 
take  the  trouble  to  cari'y  it  out  in  a 
thorough  and  continuous  manner,  they 
cannot  expect  to  be  free  from  acne. 
Stephen  Mackenzie  (British  Journal  of 
Derm.,  Oct.,  '94). 

Treatment  of  acne  of  young  girls 
should  accomplish  the  following  ends:  1. 
Overcoming  of  coldness  of  lower  extremi- 
ties by  daily  friction  with  cologne,  spirit 
of  camphor,  or  by  flagellations  with  cold 
water.  2.  Cure  of  any  uterine  difficulty. 
3.  Relief  of  habitual  constipation.  4. 
Regulation  of  diet.  Small  meals  with 
little  fluid  at  a  time,  and  plenty  of  out- 
door walking.  5.  Avoidance  of  stiff  cor- 
sets and  stiff  collars.  Patients  should 
never  wash  with  sponges,  but  only  with 
swabs  of  absorbent  cotton,  wet  with  a 
hot  solution  of  borax  and  soda — 2  tea- 
spoonfuls  of  boric  acid,  and  1  each  of 
borax  and  bicarbonate  of  soda  to  a  quart 
of  water.  At  night  the  face  should  be 
washed  with  a  naphthol  soap.  After 
soap  has  been  used  the  patient  puts 
on  each  pustule  a  small  amount  of  a 
pomade,  prepared  as  follows:  — 

B  Resorein,  1  grain. 
Betanaphthol, 

Camphor,  of  each,  12  V2  grains. 
Cret.  preparat.,  15  grains. 
Sapon.  nigris,  30  grains. 
Sulph.  prsecip.,  100  grains.. 
Lanolin, 
Vaselin,  of  each,  1  ounce. — M. 

Next  morning  patient  should  wash  the 
face  with  spirit  of  camphor,  and,  if  she 
has  to  go  out,  applies  a  little  of  follow- 
ing:— 

IJ  Acidi  salicyl.,  15  grains. 
Zinci  oxid.,  3  drachms. 
Lanolin,  6  drachms. 
Vaselin,  12  drachms. — M. 
Face  is  then  gently  washed  and  dusted 
with    starch-powder.      Brocq     (Rev.    de 
Th6r.,  May  15,  '98). 

Hot  water  and  alcoholic  lotions  some- 


times act  promptly.  In  mild  cases  thesj 
are  applied  at  night  with  very  hot  water, 
either  pure  or  combined  with  cologne- 
water  or  camphorated  alcohol.  The 
water  is  gradually  reduced  until  pure 
camphorated  alcohol  or  cologne-water  is 
used.  Boric  acid  or  borax  may  be  added 
to  the  lotions:    1  part  to  50. 

Hot  oil,  used  as  a  wash,  easily  dissolves 
solid  fatty  matter.  The  comedones  are 
dissolved  and  the  skin  softened  prepara- 
tory to  the  application  of  sulphur.  Lano- 
lin should  always  be  mixed  with  oil, 
vaselin,  or  benzoated  lard.  F.  H.  Barendt 
(Liverpool  Medico-Chir.  Jour.,  No.  38, 
1900). 

Instead  of  camphorated  alcohol  there 
have  been  used  with  success: — 

Alcohol,  96°,  saturated  with  boric 
acid,  and  alcohol  with  salicylic  acid,  1 
to  30.  The  latter  is  strong  and  must  be 
used  with  care. 

Mercurial  lotions  are  efficacious  in 
some  cases,  employed  as  follows: — - 

J^   Corr.  subl.,  1  part. 
Alcohol,  90°,  100  parts. 
Dist.  water  or  rose-water,  150  parts. 

At  first  this  solution  is  weakened  with 
one-half  its  quantity  of  water;  afterward, 
if  no  irritation  has  resulted,  the  water  is 
gradually  reduced  until  the  solution  is 
employed  pure. 

Other  mercurial  preparations,  in  oint- 
ment form,  such  as  the  biniodide,  the 
iodochloride,  white  precipitate,  and  mer- 
curial plaster,  viz.: — 

5  Hydrarg.  iodochloride,  24  gi-ains. 
Axungias,  '/=  ounce. 

M.     Rub  in  vigorously. 

The  local  action  is  said  to  be  very 
energetic.  It  should,  therefore,  be  used 
at  first  with  caution.  Gailleton  (Le  Bull. 
Med.,  July,  '89). 

The  ammoniated-mercury  ointment,  5 
grains  or  30  grains  to  1  ounce,  of  great 
value.  Stopford  Taylor  (Brit.  Jour,  of 
Derm.,  Oct.,  '94). 


94 


ACNE.     TREATMENT. 


Face  to  be  washed  with  water  as  hot 
as  can  be  borne  and  some  bland  unirri- 
tating  soap,  and  then,  after  carefully  dry- 
ing the  skin,  following  lotion  is  applied 
once  a  day: — 

R  Hydrargyrum  bichloridi,  12  grains. 
Spiritus  vini  rectif.,  6  ounces. — M. 

Effect  for  first  few  days  will  be  to 
render  condition  worse;  but,  after  this, 
lotion  prevents  perforation  of  pustules. 
G.  Gorden  Campbell  (Montreal  Med. 
Jour.,  Apr.,  '98). 

Formaldehyde  has  recently  been  tried 
with  success. 

Case  in  which  intradermal  injections 
of  formaldehyde,  in  strength  of  1  drop  of 
the  40-per-eent.  solution  to  100  drops  of 
water,  were  used.  Injections  are  at- 
tended with  a  stinging  pain.  One-half 
to  1  minim  was  injected  in  each  point 
selected,  care  being  taken  to  pass  the 
needle  into,  but  not  under,  the  skin.  In 
a  few  moments  a  spot  about  the  size  of 
ten-cent  piece  presents  an  elevated  sur- 
face resembling  urticaria.  A  sufficient 
number  of  injections  were  made  at  each 
treatment  to  thus  affect  the  whole  area 
of  disease,  and  treatment  repeated  at  in- 
tervals of  one  week.  Result  had  been 
most  gratifying.  J.  T.  McShane  (Amer. 
Assoc.  Jour.;   Ind.  Med.  Jour.,  May,  '98). 

Sulphur  preparations  are  especially 
useful  when  much  seborrhcea  exists.  In 
a  few  patients  sulphur  preparations 
cannot  be  used,  owing  to  the  irritation 
caused.  Sulphur  may  be  employed  in 
the  following  ways: — 

Sulphur-soap:  with  hot  water,  the  suds 
being  allowed  to  dry  on  to  the  face. 

Sulphur-baths. 

Sulphur-lotions:  hot  water  with  10 
to  60  drops  for  every  one-half  glass  of 
liquid  potassium  polysulphide. 

An  effective  method  of  using  sulphur 
is  the  following: — 

After  washing  with  hot  water  and 
soap,  the  following  mixture  is  applied 
with  a  camel's-hair  brush: — 


I^  Precipitated  sulphur, 
Potassium  bicarbonate, 
Glycerin, 
Laurel-water, 

Alcohol  (60°),  of  each,  2  drachms. 
— M. 

The  coating  is  left  on  during  night- 
time and  washed  off  in.  the  morning  with 
an  emulsion  of  almond-oil,  and  the  skin 
is  covered  with  oxide-of-zinc  or  bismuth- 
subnitrate  ointment  powdered  over  with 
fine  starch. 

When  the  skin  becomes  irritated,  the 
sulphur  paste  should  be  discontinued  and 
the  zinc  ointment  applied  alone  until  the 
irritation  has  disappeared. 

The  following  are  useful: — 

ly,  Sulphate  of  zinc, 

Sulphuret  of  potassium,  of  each,  1 

drachm. 
Water,  4  ounces. 

IJ   Precip.  sulphur,  4  drachms. 
Ether,  4  drachms. 
Alcohol,  enough  to  make  4  fluid- 
ounces. 

]^  Precip.  sulphur,  2  drachms. 
Gum  tragacanth,  20  grains. 
Camphor,  20  grains. 
Lime-water,  2  fluidounces. 
Water,   enough   to   make   4   fluid- 
ounces. 

Sulphur  ointments  are  usually  made 
in  the  proportion  of  1  in  10,  with  benzo- 
ated  lard,  simple  cerate,  vaselin,  vaselin 
and  lanolin,  lanolin  and  sweet  almond- 
oil  or  olive-oil,  or  castor-oil  and  cacao- 
butter. 

To  the  sulphur  may  be  added  oxide 
of  zinc  in  equal  parts;  borax,  1  to  20; 
salicylic  acid,  1  to  50;  naphthol,  1  to  10 
or  1  to  20;  resorcin  or  camphor,  1  to  20 
or  1  to  40.  They  may  be  perfumed  with 
essence  of  rose,  bergamot,  or  balsam  of 
Peru  if  desired. 


ACNE.    TREATMENT. 


95 


Sulphur  soaps  are  sometimes  more 
convenieut. 

The  following  may  be  used: — 

Soap  and  precipitated  sulphur,  equal 
parts. 

Soap,  precipitated  sulphur,  and  juni- 
per-oil, equal  parts. 

Soap,  precipitated  sulphur,  and  lard, 
equal  parts. 

Naphthol  may  be  added  to  the  first  ol 
the  series. 

The  "scaling"  method  by  the  various 
medicated  soaps  advocated.  The  soap  is 
applied  by  lathering  well  into  the  skin, 
and  then  partly  removing  it  with  luke- 
%\arm  water,  and  allowing  the  remainder 
to  dry  into  the  skin.  The  soap  contain- 
ing some  combination  of  resorcin,  sali- 
cylic sulphur,  and  balsam  of  Peru  (Eich- 
hoff)  gives  the  best  results.  Julius 
Miiller  (Dermat.  Zeitsch.,  Nov.,  '99). 

Among  other  local  treatments  recom- 
mended are  the  application  to  the  pust- 
ules of  tincture  of  iodine,  carbolic  acid, 
nitrate  of  silver,  salicylic  acid,  or  resor- 
cin. An  ointment  of  ichthyol,  1  to  4 
or  1  to  8,  is  also  useful. 

Resorcin  has  been  made  use  of  in  the 
treatment  of  ichthyosis  and  acne.  W. 
Allan  Jamieson  (London  Lancet,  Sept. 
12,  '91). 

Results  following  the  application  of 
pure  carbolic  acid  to  each  pustule  most 
satisfactory.  Very  bad  cases  are  soon 
benefited  if  the  applications  are  care- 
fully made.  P.  Abrahams  (Brit.  Jour,  of 
Derm.,  Oct.,  '94). 

ResOTcin-sublimate  paste  of  great 
value.  Unna  (Brit.  Jour,  of  Derm.,  Oct., 
'94). 

The  following  resorcin  paste  is  recom- 
mended:— 

I^  Besorcin,  2  V,  to  5  parts. 

Zinc  oxide, 

Starch,  of  each,  5  parts. 

Vaselin,  12  V2  parts. — M. 
This  paste  may  remain  on  a  day  and  a 
night  and  then  be  removed  with  a  piece 


of  cotton.     Cure  is  said  to  be  speedy, 
occurring  in  three  or  five  days. 

Salicylic  acid  acts  well  in  from  1  to 
2  ^/j  per  cent,  in  various  ointments. 

Combination  of  the  iodides  and  bro- 
mides of  potassium  with  soap,  the  latter 
possessing  keratolytic  qualities.  Two 
varieties:  strong  soaps  containing  from 
2  to  6  per  cent,  of  sodium  iodide  and 
from  1  to  3  per  cent,  of  potassium  iodide ; 
weak  soaps,  containing  but  from  1  to  3 
per  cent,  of  potassium  iodide  and  bro- 
mide. Useful  to  allow  suds  to  dry  upon 
site  of  application.  Bardach  (Lyon  Med., 
June  23,  '95). 

[New  treatments  should  be  used  with 
much  prudence  and  with  due  thought  to 
the  susceptibility  of  the  patient;  there 
is  a  tendency  to  reject  preparations  of 
the  iodides  and  bromides  in  acne,  because 
these  substances  cause  acne  in  many  per- 
sons; yet  in  some  rare  cases  I  have  per- 
sonally noted  improvement  in  acne  to 
follow  the  use  of  minute  doses  of  sodium 
■  or  potassium  iodide  and  of  applications 
of  tincture  of  iodine;  it  must  never  be 
forgotten,  however,  that  idiosyncrasy 
may  play  a  most  important  part  in  any 
medication.  L.  Beocq,  Assoc.  Ed.,  An- 
nual, '96.] 
Electrolysis  has  been  recommended  for 
the  removal  of  the  indurated  masses  left 
on  the  skin. 

In  acne  of  the  back  the  strongest  ap- 
plications, as  a  rule,  are  demanded.  Of 
especial  value  in  some  cases  is  the  liquor 
calcis  sulphuridis  (Vleminckx's  solution). 
This  should  be  used  at  first  diluted. 

Massage  of  the  face  has  recently  been 
recommended. 

Massering-ball  for  .use  in  the  local 
treatment  of  acne.  A  ball  set  in  a  steel 
socket,  the  small  sphere  rotating  within 
the  cup  of  the  latter,  as  in  the  ordinary 
ball-and-socket  joint.  The  skin  is  first 
operated  upon  with  disinfected  needle 
and  comedo-extractor,  until  all  pustules 
and  subepidermic  foci  are  emptied.  The 
surface  is  then  rendered  aseptic  with  a 
solution  of  formalin  (40  per  cent,  of  for- 
mic aldehyde),  V=  per  cent,  to  2  per  cent., 
according    to    the    sensitiveness    of    the 


96 


ACNE  ROSACEA. 


patient's  face.     The  massering-ball  then 
rotated  freely  over  the  surface,  and  deep 
pressure  made  upon  the  affected  region. 
James    Nevins    Hyde    (Jour.    Cut.    and 
Genito-Urin.  Dis.,  Mar.,  '96). 
Before   undertaking   the   local   treat- 
ment of  acne  it  is  well  to  open  the  pust- 
ules, empty  the  comedones  and  sebaceous 
cysts,  etc.     Other  direct  surgical  meas- 
ures consist  in  cauterizations  with  the 
hot  needle  or  electrolytic  needle  or  in 
scarifications.     These  are  often  satisfac- 
tory in  indurated  and  rebellious  acne. 

The  galvanoeautery  recommended  in 
acne.  Infiltration  anaesthesia  is  pro- 
duced, and  a  cautery  needle,  similar  to 
that  employed  in  epilation,  is  introduced 
to  a  depth  of  about  two  millimetres. 
Bloebaum  (Deut.  med.  Zeit.,  No.  52,  '98). 
Ichthyol  is  particularly  beneficial  both 
in  acne  vulgaris  and  acne  rosacea.  In 
the  former  strong  external  applications 


Massering-ball.     {J.  Nevins  Hyde. 


can  be  borne,  but  in  the  latter  much 
weaker  strengths  must  be  used.  The 
best  results  are  obtained  when  external 
and  internal  treatment  are  combined, 
and  in  some  cases  of  acne  rosacea  in 
which  the  skin  is  too  thin  and  irritable 
to  bear  even  weak  solutions  the  inter- 
nal administration  of  ichthyol  alone 
with  steaming  will  suffice  to  effect  a 
cure.  The  general  plan  of  treatment  is 
to  begin  with  5  grains  of  ichthyol  thrice 
daily  after  food,  increasing  to  10  grains. 
Every  night  and  morning  the  face  is 
steamed  for  fifteen  minutes  and  then 
washed  with  ichthyol  soap  made  into  a 
lather  and  allowed  to  dry  on,  which  is 
then  gently  washed  off  with  water. 
After  each  washing,  if  it  can  be  borne, 
ichthyol  salve  (often  combined  with  am- 
moniated  mercury)  is  applied.  In  acne 
vulgaris,  after  steaming,  strong  sulphur 
and  ichthyol  soap  is  used,  with  brisk 
rubbing  by  means  of  a  flesh  glove.  The 
diet  is  regulated.    Ichthyol  itself  relieves 


mild  cases  of  constipation,  but,  if  it  does 
not,  a  compound  pill  of  iridin  and 
euonymin  or  podophyllin  may  be  given. 
Alexander  Brownlie  (N.  Y.  Lancet,  May, 
1901). 

Exposure  to  Roentgen  rays  causes 
atrophy  of  the  cutaneous  follicles  and 
checks  pus-formation.  Series  of  per- 
sonal cases  with  interesting  results. 
Case  I,  aged  22,  treated  for  hypertri- 
chosis, but  had  moderately  severe  acne 
simplex.  The  lesions  were  usually  in- 
dolent, inflammatory  papules  without 
much  induration  and  rarely  with  the 
formation  of  well-marked  pustules.  She 
was  exposed  to  the  x-rays  for  three 
months,  with  a  production  of  some  der- 
matitis, and  she  has  been  under  similar 
treatment  at  intervals  during  the  year. 
After  the  development  of  the  first 
erythema  her  acne  disappeared,  and  she 
had  no  lesions  within  the  last  year. 
Case  II  was  practically  identical  with 
Case  I.  Case  III,  aged  26,  treated  for 
hypertrichosis,  slight  acne,  comedones, 
and  constantly  recurring  outbreaks  of 
a  few  indolent,  inflammatory  papules. 
After  the  first  erythema  she  has  had 
no  acne  lesions.  In  all  of  the  above 
cases  the  skin  is  smooth  and  soft,  and 
the  result  is  satisfactory  from  a  cos- 
metic point  of  view.  William  A.  Pusey 
(Jour,  of  Cutaneous  and  Genito-urin. 
Dis.,  May,  1902). 

Treatment  of  acne  by  exposure  to  the 
x-rays  tried  in  fifteen  cases.  With  one 
exception,  satisfactory  results  were  ob- 
tained. The  cases  were  not  selected. 
R.  R.  Campbell  (Jour.  Amer.  Med.  As- 
soc, Aug.  9,  1902). 

Henky  W.  Stelwagon, 

Philadelphia. 

ACNE  ROSACEA. 

Definition.  —  Acne  rosacea  is  charac- 
terized by  a  chronic  congestion  of  the 
face,  causing  vascular  dilatations;  and 
by  changes  in  the  cutaneous  glands  and 
tissues,  giving  rise  to  seborrhoea,  inflam- 
matory acne,  and  hypertrophic  changes. 

Symptoms. — The  nose  and  malar  emi- 
nences are  especially  prone  to  this  dis- 
order.   It  may  also  affect  the  forehead. 


ACNE  ROSACEA.    SYMPTOMS.    ETIOLOGY. 


97 


chin,  the  neighborhood  of  the  alae  nasi, 
the  cheeks,  and  less  commonly  the  side 
of  the  neck.  In  women  the  chin  is  occa- 
sionally invaded. 

There  are  three  forms  of  acne  rosacea. 

The  first  is  the  erythematous  and 
telangiedasic.  It  may  be  characterized 
by  temporary  congestive  spots  on  the 
face,  showing  themselves  especially  after 
meals  and  in  the  evening.  These  spots 
may  be  accompanied  by  no  other  lesion. 
This  form  is  usually  present  in  connec- 
tion with  more  or  less  seborrhoea,  espe- 
cially on  the  nose,  which  is  generally 
very  oily.  Again,  the  erythematous 
variety  may  be  characterized  by  small 
vascular  dilatations  on  the  nose  or  malar 
eminences,  which  dilatations  develop 
gradually,  unite  with  one  another,  and 
form  a  net-work.  This  net-work  is  uni- 
form in  hue  at  a  distance,  but  near  by 
may  be  seen  to  be  formed  of  congested 
surfaces  over  which  are  spread  vascular 
dilatations.  This  degree  of  the  erythem- 
atous form  is  almost  always  accompanied 
by  seborrhoea,  enlarged  nose,  and  dilated 
glandular  orifices,  especially  in  women 
toward  the  menopause  and  in  wine- 
drinkers.    (Hebra.) 

The  nose  may  become  slightly  violet- 
hued  and  be  cold  to  the  touch. 

The  second  form  is  the  erythematous 
acne,  or  true  acne  rosacea.  In  addition  to 
the  erythematous  and  congestive  feature, 
there  may  be  found  in  this  variety  a  true 
acneic  element:  papules  and  pustules.  In 
some  cases  the  acne  appears  before  the 
congestion.  There  is  a  congestive  red 
base  with  fine  vascular  dilatations  and 
papulo-pustules  of  various  sizes,  often 
resting  on  an  indurated  violet-red  base. 

In  this  variety  there  may  also  be  in- 
crease in  number  and  size  of  the  vascular 
•dilatations,  increase  in  size  and  depth  of 
the  acneic  indurations,  and  proliferation 
and  hypertrophy  of  the  derma. 


The  third  form  is  the  hypertrophic 
acne,  or  rhinophyma.  In  this  variety 
the  glandular  orifices  are  much  enlarged, 
while  the  glands  themselves  may  be  ten 
to  fifteen  times  increased  in  size.  The 
tissues  around  them  proliferate,  forming 
a  variety  of  pachyderma.  The  nose  may 
be  red  or  violet-hued,  covered  with  en- 
larged orifices,  greatly  increased  in  size, 
falling  down  to  the  chin.  Its  exterior 
may  be  mammillated.    (Broeq.) 

Two  subdivisions  of  this  form  are  ren- 
dered necessary  by  the  difference  in  the 
pathology  of  each.  The  first,  glandular, 
presents  an  embossed  aspect,  the  hyper- 
trophy being  due  especially  to  hyper- 
trophy of  the  pilo-sebaceous  glands;  the 
second,  elephantiasic,  presents  a  smooth 
aspect,  being  due  to  chronic  oedema; 
there  are  also  vascular  dilatations,  with 
sclerosis  of  the  derma.  (Vidal  and  Le- 
loir.) 

Etiology.  —  Women  suffer  more  than 
men  from  the  erythemato-telangiectasic 
and  acneic  forms.  Men  only  suffer  from 
hypertrophic  acne.  It  usually  appears 
between  30  or  40  years.  In  women, 
rosacea  develops  usually  at  from  30  to 
45  years,  and  increases  decidedly  toward 
the  menopause,  after  which  it  may  re- 
cede. It  may  also,  however,  develop  at 
puberty.  In  young  women  and  girls  it 
is  frequently  due  to  chlorosis,  dysmenor- 
rhcea,  or  sterility.  In  some  it  recurs  at 
each  conception. 

Some  authorities  claim  that,  among 
the  constitutional  causes  (which  affect 
women  more  than  men),  heredity  plays 
an  important  part.  The  disease  is  said 
to  be  more  frequent  in  children  of  arthri- 
tic subjects,  or  of  those  who  may  have 
suffered  from  acne  rosacea. 

Cold  feet,  urethral  and  uterine  dis- 
turbances, and  constipation  are  also  re- 
corded as  causes  of  the  disease.  The 
cause    of    acne    may    be    found    in    the 


98 


ACNE  ROSACEA.    PATHOLOGY.    DIAGNOSIS. 


mouth  or  teeth  and  be  unilateral  if  the 
cause  is  one-sided.    (E.  Besnier,  Doyon). 

Dyspepsia,  neuralgia,  hemicrania, 
working  with  the  head  inclined  forward, 
and  disease  of  the  nasal  fossse  are  among 
the  less  frequent  etiological  factors 
(which  affect  men  more  than  women), 
while  high  heat,  overheated  rooms,  high 
wind,  sea-air,  cold,  and  cold  water  are 
occasional  causes,  especially  in  men.  The 
disease  may  become  started  in  people 
who  for  several  years  have  indulged 
in  excessive  hydrotherapeutic  treatment 
(Kaposi). 

Certain  occupations — such  as  those  of 
coachman,  baker,  smith,  fireman,  glass- 
blower — may  also  become  primary  causes 
of  the  trouble.  Indiscretion  in  diet  and 
alcoholic  beverages  are  well-known  fac- 
tors. According  to  Kaposi,  in  wine- 
drinkers  the  nose  is  bright  red,  in 
beer-drinkers  it  is  violet,  while  in  spirit- 
drinkers  it  is  soft,  large,  and  dark  blue. 

Pathology.  —  The  vascular  dilatations 
of  the  face  have  been  considered  by  some 
authorities  as  due  to  circulatory  troubles 
caused  by  compression  of  the  veins  in  the 
cranial  foramina. 

A  certain  paretic  condition  of  the  vas- 
cular walls  may  often  be  looked  upon  as 
a  cause.     (Brocq.) 

The  cutaneous  nerves  of  the  region 
affected  have  been  found  normal  by  E. 
Besnier.  According  to  Leloir  and  Vidal, 
however,  there  is  congestion  of  the  deeper 
venous  net-work  of  the  skin;  dilatation 
of  the  same  vessels  and  of  the  perifollic- 
ular vascular  net-work,  their  walls  being 
often  diminished  in  thickness.  There  is 
also  formation  of  new  vessels. 

Diagnosis. — Ltjpus  Erythematosus. 
—  The  superficial,  congestive  variety 
shows  a  brighter  and  better  defined 
redness;  crusts  or  squamae  on  the  sur- 
face; sharper  and  more  definite  edges; 
greater  sensitiveness  to  pressure;   slight 


elevation  above  the  surrounding  surface. 
If  any  cicatrix  be  present,  it  is  surely 
lupus  erythematosus. 

ClHCUMSCEIBED     CONGESTIVE     SeBOK- 

EHCEA.  —  In  this  disorder  there  is  a 
limited  extent  of  patches,  shallower  and 
more  uniform  redness,  with  crusts  cover- 
ing them. 

Keratosis  pilaris  is  recognized  by 
its  inframalar  and  preauricular  location, 
and  the  file-like  feeling,  to  the  finger, 
of  the  erythematous  and  telangiectasic 
patches. 

Sycosis  Non-pa-rasitica.  —  This  is- 
always  an  inflammatory  disease  of  the 
hair-follicles  and  perifollicular  tissues. 
There  are  numerous  papules  and  pust- 
ules, each  perforated  by  a  hair,  and  often 
capped  by  a  small  circular  scale.  The 
upper  lip  and  chin  are  sites  of  predilec- 
tion.   The  affection  is  usually  painful. 

Congenital  adenoma  sebaceum  also- 
has  a  special  location:  the  naso-genial 
furrow,  the  parts  aroimd  the  nose,, 
mouth,  and  chin.  It  presents  a  mame- 
lated  aspect,  and  its  predilection  for 
early  youth  and  its  normal  evolution 
serve  to  establish  its  identity. 

Eczema.  —  Erythematous,  or  pustulo- 
papular,  eczema  of  the  face  may  some- 
times present  diagnostic  difficulties.  In 
this  disease,  the  more  or  less  constant, 
and  usually  intense,  itching,  the  serous 
or  sero-purulent  secretion,  and  the  des- 
quamation will  suffice  to  establish  the- 
diagnosis. 

Psoriasis  of  the  Face.  —  Diagnosis 
is  also  frequently  difficult  in  this  dis- 
order. The  patches  are  better  defined 
and  are  generally  covered  by  silvery- 
white  scales  situated  on  a  red  base,  which 
bleeds  easily  on  scratching.  The  pres- 
ence of  typical  psoriasie  patches  on  other- 
portions  of  the  body  is  an  important 
sign. 

Chilblains. — Changeableness  of  the- 


ACNE  ROSACEA.     PROGNOSIS.     TREATMENT. 


99 


lesions   and   pains   are   peculiar   to   this 
disorder. 

AcNEiFOEM  Syphilides.  —  Here  the 
manner  in  which  the  elements  are 
grouped,  the  long  duration  of  their 
evolution,  their  tendency  to  ulceration, 
and  consecutive  cicatrix  are  important. 
Complete  failure  of  acneic  remedies  is 
.another  diagnostic  point. 

Ehinosclekoma.  —  In  this  disorder 
there  are  hard  or  ivory-like  masses  im- 
bedded in  the  nose. 

Prognosis.  —  Acne  rosacea  does  not 
always  increase;  it  may  remain  station- 
ary or  even  recede,  especially  in  women 
after  the  menopause.  It  may  also,  how- 
ever, assume  malignancy,  hut  this  sequel 
is  very  rarely  met  with. 

Case  of  a  man,  67  years  old,  with  a 
well-marked    hypertrophic    acne    of    the 
nose;    one  of  the  masses  having  been  re- 
moved  by   ligature,   an   epitheliomatous 
ulcer  supervened,  and  tlie  growth  grad- 
ually' took  on  epitheliomatous  transfor- 
mation.    Matignon    (Jour,    de   Med.    de 
Bordeaux,  Dec.  6,  '91). 
Treatment. — As  to  general  treatment, 
it  is   especially  necessary  to  pay  strict 
attention  to  the  good  condition  of  the 
stomach  and  intestines,  by  appropriate 
measures  and  suitable  diet.     Purgatives 
are   absolutely   necessary   from   time   to 
time;     laxatives    should    frequently    be 
given  and  constipation  should  be  avoided 
(Brocq). 

Proper  circulation  of  lower  limbs 
should  be  insured  by  adequate  clothing. 
Any  abnormal  condition  of  the  genito- 
urinary tract  or  of  the  upper  respiratory 
tract,  especially  the  nose,  should  be  cor- 
rected, while  anything  tending  to  cause 
congestion  of  the  face,  such  as  tight 
collars  or  stays,  should  carefully  be 
avoided.  Sedentary  intellectual  work, 
especially  by  gaslight,  frequently  aggra- 
vates these  cases. 

As  a  rheumatic  diathesis  is  a  dominant 


etiological  factor,  various  alkalies  have 
been  recommended,  especially  bicarbon- 
ate of  soda  or  the  various  alkaline  waters. 

Where  the  face  is  intermittently  con- 
gested, quinine,  ergotine,  belladonna, 
digitalis,  and  hamamelis  have  seemed 
useful.  These  may  be  combined  in  a 
mixture,  with  or  without  the  tincture  of 
aconite-root.  *  Vasoconstrictor  drugs  have 
but  little  influence. 

Perchloride  of  iron,  tannin,  ergot,  and 
tincture  of  hamamelis  are  recommended 
by  E.  Besnier  and  A.  Doyon. 

The  following  preparation  is  extolled 
by  Brocq: — 

I^   Quinine  hydrobromate, 

Ergotine,  of  each,  30  grains. 

Belladonna  extract,  6  to  12  grains. 

Lithium  benzoate,  30  grains. 

Excipient  and  glycerin,  q.  s. 
M.    For  forty  pills. 
Sig.:    Two  before   each   of   the   two 
principal  meals. 

Ehubarb  or  aloes  may  also  be  added  if 
necessary. 

Amyl-nitrite  may  be  inhaled  or  taken 
internally  by  patients  suifering  from 
congestive  attacks  of  the  face.  (Sidney 
Einger.) 

The  local  therapeutic  agents  are  the 
same  as  in  acne  vulgaris;  though  some 
irritable  varieties  of  acne  rosacea  exist,  it 
is  usually  necessary  to  act  with  greater 
energy. 

Hot  water  and  mercurial  preparations 
are  often  of  value.  Mercurial  ointment 
may  be  rubbed  in  pure  or  weakened  with 
lard,  twice  daily,  according  to  individual 
susceptibility.    (Hardy.) 

The  following  has  been  employed  by 
Bazin  with  success: — 

I^   Mercury    biniodide,    7  ^/^    to    15 
grains. 
Lard,  1  ounce. — M. 


100 


ACNE  ROSACEA.     TREATMENT. 


Sulphur  preparations  are  also  useful; 
but,  as  the  preparations  should  be  strong 
enough  to  cause  irritation  of  the  integu- 
ments, it  is  well  to  use  sulphur  pastes 
mixed  with  green  soap. 

In  eases  of  average  intensity  derma- 
tologists frequently  employ  Vleminckx's 
solution,  at  first  with  5  parts  of  water, 
then  gradually  making  it  stronger  until 
it  is  used  pure.  It  should  be  left  on 
several  minutes,  and  followed  by  very 
hot  water. 

Green  soap  gives  the  best  result  in  ob- 
stinate acne  rosacea,  alone  or  when  used 
in  conjunction  with  sulphur,  naphthol, 
or  salicylic  acid.     It  may  be  used  as  in 
acne  vulgaris  or  spread  on  a  piece  of 
flannel;   the  latter  is  then  cut  out  to  fit 
the  affected  region,  and  left  on  as  long 
as   possible.     When   the   irritation   be- 
comes too  great,  the  application  should 
cease  and  cooling  preparations,  such  as 
the  following,  be  used: — 
I^   Salicylic  acid,  7  grains. 
Zinc  oxide. 
Bismuth    subnitrate,    of    each,    30 

grains. 
Lycopodium,  V2  drachm. 
Vaselin,  2  drachms. 
Lanolin,  3  drachms. 
Ichthyol  does  not  seem  to  be  as  effi- 
cacious in  acne  rosacea  as  in  some  other 
varieties  of  acne  (Brocq). 

Ichthyol  is  often  better  than  sulphur 
as  a  reducing  agent.     Purdow    (Dublin 
Jour.  Med.  Sci.,  May,  '94). 
Unna  recommends  daily  doses  of  7  ^7, 
grains  of  ichthyol  internally  and  lotions 
with  ichthyol  dissolved  in  water,  washing 
with  ichthyol-soap.     Steam  or  sulphur- 
water  douches,  pyrogallic  acid,  and  chry- 
sarobin  have  also  been  used  with  good 
results.    Turpentine  has  also  been  found 
efficacious. 

Turpentine   has   a   solvent   action    on 
the  sebaceous  secretion;     it   also  exerts 


a   disinfecting  action  that  prevents  the 

spread  of  the  affection.     Cases  in  which 

it  proved   very  efficacious.     It  produces 

violent  smarting  and  redness,  but  these 

effects  disappear  in  a  few  hours.     Betz 

(London  Lancetj  Jan.  30,  '97). 

Liquor  gutta  perchse  may  be  used  to 

exert  pressure  on  the  vessels  and  thus 

encourage  resolution  of  the  parts. 

A  solution  of  iodine  in  glycerin,  ap- 
plied twice  daily  during  three  or  four 
daj's,  is  recommended  by  Kaposi. 

Treatment  of  acne  rosacea  is  divided 
into  constitutional  and  local.  In  women 
any  menstrual  disorder  should  be  cor- 
rected, all  alcoholic  stimulants  should  be 
stopped,  and  good  plain  diet  taken.  If 
tongue  is  very  coated  alkaline  bitter 
tonic  should  be  ordered.  When  skin  is 
much  thickened,  and  there  are  many 
acne  papules  and  pustules,  German  green 
soap  is  best,  used  with  hot  water,  and 
a  piece  of  white  flannel,  every  night, 
until  the  skin  begins  to  peel  consider- 
ably. In  less  severe  cases  white  Castile 
soap  is  good.  Five-per-cent.  resorcin  soap 
(Eiehhoff's)  is  very  efficacious.  Prescrip- 
tion for  an  ointment  is  as  follows:  — 

IJ  Sulpli.  prsecip.,  1  to  4  drachms. 
Acidi  salicyl.,  10  to  30  grains. 
01.  amygdal.  dulcis,  1  drachm. 
Lanolin,   1  ounce. 
M.     Sig. :    Apply  at  night  after  wash- 
ing.     (The   salve  should  not  he  gritty, 
but  perfectly  smooth.)      T.   C.   Gilchrist 
(Maryland  Med.  Jour.,  Dec.  10,  '98). 

Blisters,  left  on  but  four  or  five  hours, 
are  used  by  some  dermatologists. 

Surgical  treatment  in  this  disease  is 
the  most  efficacious.     (Brocq.) 

Kummerfeld's  solution,  used  in  vary- 
ing   strength    according    to    severity    of 
case,  will  be  found  efficacious,  especially 
in  connection  with  scarification:  — 
R  Sulph.  prtecip.,  1  to  3  drachms. 
Pulv.  camph.,  5  grains. 
Pulv.  tragacanth.,  10  grains. 
Aquae  calcis,  1  ounce. 
Aquae  rosse,  1  ounce. 
M.     Sig.:      Apply    after    washing    at 
night. 


ACNE  ROSACEA.     TREATMENT. 


101 


Scarification  or  the  application  of  the 
electrical  needle  is  a  very  necessary  ad- 
junct to  the  treatment. 

Scarification  can  he  done  in  three 
ways:  1.  By  linear  scarification.  2.  By 
slitting  up  the  dilated  cutaneous  blood- 
vessels. 3.  By  puncturing  rapidly.  The 
third  plan  is  best.  T.  C.  Gilchrist  (Mary- 
land Med.  Jour.,  Dec.  10,  '98). 

In  typical  acne  rosacea  the  pustules 
are  first  emptied,  then  cauterized  with  a 
fine-pointed  thermo-  or  galvano-  cautery. 
Vascular  dilatations  promptly  yield  to 
cauterization  with  a  very  fine  point 
heated  by  electricity  or  a  simple  needle 
heated  in  the  fire. 

Electrolysis  is  another  satisfactory 
method.  A  fine  platinum  needle  is  in- 
serted alongside  of  the  vessel,  and,  if 
possible,  into  it,  and  connected  with  the 
negative  pole,  while  the  patient  holds  in 
his  hand  a  cylinder  in  communication 
with  the  positive  pole.  A  large  eschar 
must  be  avoided.    (Hardaway.) 

The  ordinary  galvanic  or  faradic  cur- 
rents have  been  recommended  by  Cheadle 
and  Piffard. 

Scarification  is  a  favorite  method. 
The  best  instrument  is  Vidal's  ordinary 
scarificator.  The  skin  is  cut  obliquely 
or  perpendicularly  to  the  vessels,  then 
slightly  obliquely  across  these  so  as  to 
form  lozenges,  and  as  near  together  as 
possible  (from  one  to  one  and  a  half  mil- 
limetres apart),  and  not  deep  enough  to 
penetrate  entirely  through  the  dermis, 
so  as  to  avoid  cicatrices. 

An  hoitr  afterward  the  part  is  washed 
with  a  corrosive-sublimate  solution,  1  to 
1000;  then  in  the  evening  or  the  follow- 
ing day  compresses  dipped  into  an  am- 
monium-hydrochlorate  solution,  1  to 
100,  or  corrosive  sublimate,  1  to  500,  are 
applied.  If  too  strong,  warm  water  is  to 
be  added.  If  the  reaction  is  too  violent, 
starch-poultices,  bland  pomatums,  or 
zinc-oxide  plasters  can  be  employed. 


The  treatment  should  be  renewed  in 
from  five  to  eight  days.  Amelioration 
will  occur  in  from  eight  to  ten  sessions; 
and  marked  improvement  in  from  fifteen 
to  twenty-five  sessions. 

Scarifying  should  be  begun  in  the 
lower  part  of  the  region  to  be  operated 
upon,  in  order  not  to  be  troubled  by  the 
blood  covering  the  surface.  (E.  Besnier, 
A.  Doyon.) 

In  the  early  stage  of  hypertrophic  acne 
the  scarification  must  be  made  deeper, 
and  in  many  cases  it  is  essential  to  also 
cauterize  the  glands  deeply. 

Electrolysis  of  each  dilated  sebaceous 
follicle  with  a  negative  platinum  needle 
and  a  current  of  from  4  to  6  milliam- 
peres  is  an  effective,  though  tedious, 
measure.  The  needle  should  be  moved 
around  in  the  follicle  in  order  to  thor- 
oughly destroy  it.  In  the  advanced 
hypertrophic  form  direct  removal  with 
the  knife  is  the  best  procedure.    (Brocq.) 

Hypodermic  injections  of  alcohol  have 
recently  been  recommended. 

Local  subcutaneous  injections  of  95- 
per-cent.  alcohol.  The  part  is  compressed 
with  the  fingers,  and  20  or  30  drops  of 
alcohol  injected  with  a  clean  hypodermic 
syringe  with  a  thin  needle.  The  immedi- 
ate effect  of  the  injection  is  a  local  swell- 
ing and  ansemia,  lasting  but  a  few  mo- 
ments; then  an  increased  redness  lasting 
from  half  an  hour  to  three  or  four 
hours;  this  gradually  disappears,  and 
the  treated  skin-area  assumes  normal 
color.  The  dilated  blood-vessels  and 
papules,  after  repeated  injections,  un- 
dergo slow  obliteration,  until  finally  the 
whole  lesion  disappears  and  the  affected 
integument  appears  normal.  The  treat- 
ment, in  some  cases,  lasts  eight  or  ten 
weeks;  in  others,  a  great  deal  longer. 
R.  Abrahams  (Amer.  Med.-Surg.  Bull., 
May  16,  '96). 

Geoege  H.  Eohe. 

Baltimore. 


102 


ACONITE.     PEEPAEATIOKS.     PHYSIOLOGICAL  ACTION. 


ACONITE. — The  preparations  of  aco- 
nite usually  employed  are  obtained  from 
the  root  of  the  Aconitum  napellus 
(monk's-hood):  a  conical  tuber  greatly 
resembling  horse-radish.  This  resem- 
blance has  caused  many  deaths.  When 
scraped,  however,  aconite-root  does  not 
emit  the  pungent  odor  peculiar  to  horse- 
radish. Again,  instead  of  irritating  the 
palate,  as  does  horse-radish,  aconite-root, 
when  masticated,  soon  produces  in  the 
moiith  a  sense  of  warmth  and  tingling, 
soon  followed  by  local  numbness  varying 
in  duration  according  to  the  length  of 
time  the  mucous  membrane  is  exposed  to 
the  efJects  of  the  drug. 

The  active  principle  of  aconite,  aconi- 
tine,  will  be  considered  in  the  next 
article. 

Preparations  and  Dose.  —  Aconite  in 
substance  is  not  employed,  and  the 
preparations  made  with  the  leaves  are 
no  longer  of&cial. 

The  tincture  (tinctura  aconiti  rad., 
U.  S.  P.)  is  three  times  stronger  than 
either  the  English  or  French  tinctures. 
Dose,  1  to  3  minims,  every  three  hours. 
Its  effects  should  be  closely  watched, 
especially  in  anemic  and  corpulent  indi- 
viduals and  in  those  addicted  to  alcohol. 

Fleming's  tincture  is  no  longer  offi- 
cial and  should  not  be  employed. 

The  fluid  extract  (extractum  aconiti 
fluidum,  U.  S.  P.),  V^  to  2  minims,  every 
three  hours. 

The  solid  extract  (extractum  aconiti, 
U.  S.  P.),  V,  to  V4  grain. 

Physiological  Action. — Within  half  an 
hour  after  its  administration  the  drug 
commences  to  afJect  the  general  system, 
slowing  and  weakening  the  heart's  ac- 
tion, lowering  arterial  tension,  increasing 
the  action, of  the  skin  and  kidneys,  and 
producing  more  or  less  muscular  weak- 
ness in  proportion  to  the  amount  taken. 
It  causes  a  tingling  sensation  in  the  lips, 


extremities,  and,  perhaps,  the  whole 
body;  it  diminishes  the  rapidity  and 
depth  of  the  respiration,  and  causes  dis- 
orders of  vision  and  loss  of  tactile  sensi- 
bility and  sense  of  pain.  According  to 
Wood,  aconite,  when  administered  in 
sufficient  dose,  is  a  powerful  depressant 
of  the  sensory  nerve;  and  there  is  some 
reason  for  believing  that  the  stage  of 
nerve-paralysis  is  preceded  by  one  of 
nerve-stimulation.  Subsequently,  how- 
ever, its  action  on  the  spinal  cord  was 
further  ascertained,  and  Bartholow  states 
that  aconite  affects  the  sensory  nerves 
before  the  motor.  It  paralyzes  first  the 
end-organs,  next  the  nerve-trunks,  and 
finally  the  centres  of  sensation  in  the 
cord.  It  also  impairs  the  reflex  function 
of  the  cord,  but,  doubtless,  secondarily 
as  regards  the  sensory  paralysis.  The 
power  of  voluntary  movement,  which 
continues  after  the  cessation  of  the  reflex 
functions,  is  finally  lost,  owing  to  the 
action  on  the  motor  centres  of  the  cord, 
and  subsequently  on  the  nerve-trunks. 

Pyraconitine,  obtained  from  aoonitine 
by   heating   to    separate   a   molecule    of 
acetic    acid,   causes   no   tingling   of   the 
lips  or  tongue.    It  causes  slowing  of  the 
heart,     partly     from     vagus     irritation, 
partly   from    depression   in   function    of 
intrinsic  rhythmical  and  motor  mechan- 
isms.    After  its  administration  activity 
of  respiration  is  reduced  (by  central  de- 
pression) to  a  degree  incompatible  with 
life.      Neither    muscular    nor    intramus- 
cular  nervous   tissue   is   strongly   influ- 
enced   by   pyraconitine,   but   the    spinal 
cord  is  impaired  in  its  reflex  function, 
and  tliere  is  a  curious  condition  of  ex- 
aggerated motility.    Theodore  Cash  and 
W.  K.  Durstan  (Brit.  Med.  Jour.,  Aug. 
17,  1901). 
When  aconite  is  applied  directly  to 
the  heart,  the  number  and  force  of  the 
beats  are  lessened,  and  its  action  is  finally 
arrested  in  diastole.    It  lowers  the  blood- 
pressure  and  pulse-rate  when  given  in- 
ternally by  a  direct  action  on  the  heart 


ACONITE.     POISONING.    TREATMENT. 


103 


itself.  Bartholow  concludes  that  it  is  a 
direct  cardiac  poison,  afEecting  its  gan- 
glia and  muscle,  and  also  a  sedative  to 
the  vasomotor  nerve-system.  Hare  calls 
attention  to  the  fact  that  the  fall  in 
pulse-rate  from  poisonous  doses  is  some- 
times preceded  by  a  quickening  due  to  a 
condition  of  weakness  and  abortive  car- 
diac action.  All  agree  that  it  is  a  re- 
spiratory poison  by  direct  action  on  the 
muscles  of  respiration,  but  that  the  heart 
ceases  before  the  respiratory  movements. 

Aconite  reduces  the  temperature  when 
given  in  health.  Bartholow  tells  of  a 
medical  student  poisoned  with  aconite, 
in  whom  the  temperature  fell  two  de- 
grees. It  also  increases  the  action  of  the 
skin  and  kidneys,  and  with  the  increase 
of  water  there  is  augmentation  of  the 
solids  excreted.    (F.  B.  Stewart.) 

Aconite  Poisoning.  —  The  symptoms 
following  the  ingestion  of  a  poisonous 
dose  usually  show  themselves  after  a  few 
minutes.  The  tingling,  prickling,  and 
numbness  already  mentioned  rapidly  ex- 
tend from  the  mouth  and  fauces  to  the 
face,  thence  to  the  body.  Speaking  re- 
quires marked  effort.  Great  prostration 
and  muscular  impotency  follow,  and  the 
skin  becomes  cold  and  clammy,  the  per- 
spiration covering  the  surface,  and  the 
cold  tissues  communicating  to  the  hand 
an  icy  coldness.  Muscular  pains  may  be 
present  in  the  early  stages,  especially  in 
the  face.  There  is  usually  experienced 
marked  epigastric  pain  with  nausea  and 
vomiting.  Later  on,  however,  the  nausea 
ceases,  owing  to  paralysis  of  the  stomach- 
walls. 

The  heart-beats  are  greatly  reduced  in 
number  and  power;  the  pulse  is  usually 
irregular,  compressible,  and  slow,  and 
so  weak,  at  times,  as  hardly  to  be  felt. 
The  breathing  is  labored,  irregular,  and 
shallow,  the  number  of  respirations  being 


at  first  decreased  then  increased.  The 
temperature  may  be  considerably  lowered. 

The  pupils  may  be  dilated  or  remain 
of  normal  size  and  react  equally.  The 
eyes  may  protrude  or  be  sunken;  there- 
fore they  afford  no  differential  informa- 
tion as  to  the  nature  of  the  drug. 

The  mind  is  usually  clear,  and  the 
patient  calm,  though  apprehensive  of 
impending  death.  Occasionally  epilep- 
toid  convulsions  occur.  Spasmodic  purg- 
ing, the  stools  being  sometimes  bloody, 
and  rectal  tenesmus  are  frequently  pres- 
ent. 

Aconite  causes  paralysis  of  respiration 
and  circulation,  death  usually  being  due 
to  sudden  arrest  of  the  heart  in  diastole. 

Case  of  poisoning  from  tincture  of 
aconite-root.  Two  doses  of  1  minim  each, 
given  one  hour  apart,  produced  tingling, 
mild  delirium,  diplopia,  and  other  indica- 
tions of  aconite  poisoning.  Frank  Wood- 
bury (Phila.  Med.  Times,  Jan.  1,  '90). 

Personal  case  of  death  following  a 
minimum  dose.  There  are  many  cases 
of  individual  intolerance,  and  syncope 
may  occur  in  certain  patients  from  small 
quantities.  Ferrand  (La  France  M6d., 
Dec.  8,  '93). 

Treatment  of  Aconite  Poisoning.  — 
Death  in  these  cases  usually  follows 
exertion  by  the  patient.  He  should, 
therefore,  be  kept  perfectly  motionless 
in  the  reciimbent  position  even  during 
emesis,  his  head  being  slightly  turned 
and  the  dejections  received  on  a  towel. 
An  important  feature  of  the  treatment 
is  to  keep  the  patient  as  warm  as  possible 
by  means  of  warm  blankets  and  hot- 
water  bottles,  taking  care  not  to  place 
the  latter  against  the  skin.  The  head 
should  also  be  kept  warm.  If  the  patient 
is  seen  early  the  stomach-tube  should 
be  used  at  once  to  empty  the  stomach. 
If  no  stoma  ch-tube  be  at  hand,  apomor- 
phine,  Vjo  to  Ve  grain,  should  be  ad- 
ministered hypodermically,  or  some  other 


104 


ACONITE.    POISONING.    TREATMENT. 


active  emetic,  such  as  zinc  sulphate,  15 
to  30  grains,  be  given  by  the  mouth. 

A  point  of  practical  importance,  not 
mentioned  in  the  text-books,  is  that  of 
wrapping  up  the  head  and  applying 
heaters  there.  This  apparently  gives 
especial  comfort  to  the  patient.  Elevat- 
ing the  foot  of  the  bed  is  of  some  use. 
R.  W.  Greenleaf  (Boston  Med.  and  Surg. 
Jour.,  July  15,  '97). 

Digitalis,  sulphate  of  strychnine,  and 
belladonna  are  the  most  effective  reme- 
dies, but  ether  and  ammonia  should  first 
be  employed,  owing  to  their  great  difEu- 
sibility.  All  these  remedies  should  be 
used  hypodermically,  the  stomach  being 
unable  to  perform  its  functions.  A 
drachm  of  ether,  ammonia,  brandy,  or 
whisky  should  at  once  be  injected,  and, 
aftep  a  few  minutes,  tincture  of  digitalis, 
15  minims;  strychnine  sulphate,  ^/jo 
grain;  or  tincture  of  belladonna,  10 
minims,  according  to  what  the  practi- 
tioner may  have.  The  dosage  should 
be  regulated  so  as  to  reach  the  point 
of  physiological  action  by  frequently 
repeated  doses.  Nitrate  of  amyl  may  be 
given  by  inhalation,  and  warm,  very 
strong  coffee  be  injected  into  the  rectum. 
If  the  patient  is  seen  when  the  stage 
of  depression  has  begun  through  absorp- 
tion of  the  poison,  the  stomach-pump 
shoiild  alone  be  used,  emetics  at  this 
stage  being  liable  to  cause  arrest  of  the 
heart's  action.  Tincture  of  digitalis,  in 
20-minim  doses,  should  be  injected 
hypodermically  and  repeated  as  required, 
besides  the  other  measures  indicated. 
Frictions  under  cover,  the  rubbing  being 
directed  toward  the  heart,  serve  a  useful 
purpose. 

Twenty  cases,  six  of  which  were  fatal, 
found  in  the  literature  of  the  last  ten 
years: — 

Case  1.  Tincture,  7  drachms.  Recov- 
ery. Emetics;  morphine,  V2  grain;  fluid 
extract  of  digitalis,  6  drops;  strychnine 
sulphate,  V,5o  grain;     brandy,   1   ounce; 


all  hypodermically.  By  the  mouth,  2 
gallons  of  warm  water;  fluid  extract  of 
digitalis,  20  drops;  coffee,  U  pints; 
whisky,  3  pints;  extract  nueis  vomica, 
V2  fluidraehm ;  Port  wine,  V2  pint.  P.  F. 
Brick  (Jour.  Amer.  Med.  Assoc,  vol.  viii, 
p.  567,  '87). 

Case  2.  About  8  drops  of  concentrated 
fluid  extract.  Recovery.  Emetics,  coffee, 
whisky  (dessertspoonful).  Heat.  Fric- 
tion and  sinapism.  T.  H.  P.  Baker 
(Amer.  Pract.  and  News,  vol.  iv,  N.  S., 
p.  122,  '87). 

Case  3.  Fleming's  tincture,  1  '/j  ounces. 
Recovery.  Emetics,  brandy,  ether,  digi- 
talis, ammonia  carbonate.  Amyl-nitrite 
and  warmth.  C.  C.  Bradley  (N.  Y.  Med. 
Record,  vol.  xxxii,  p.  155,  '87). 

Case  4.  Tincture,  '/^  ounce.  Recovery. 
Brandy  by  mouth  and  hypodermically. 
Ether.  One  quart  of  cold,  black  coffee. 
Heat  and  posture.  S.  Barnett  (N.  Y. 
Med.  Record,  vol.  xxxii,  p.  761,  '87). 

Case  5.  Amount  not  known.  Patient 
intoxicated  at  the  time.  Symptoms  of 
acute  poisoning.  Recovery.  Emetics, 
brandy,  ammonia,  and  digitalis  by  the 
mouth.  Sixty  minims  of  tincture  of 
digitalis  hypodermically.  Heat.  Clara 
T.  Dercum  (Med.  and  Surg.  Reporter, 
vol.  Ixi,  p.  376,  '89). 

Case  6.  Tincture,  amount  not  known. 
Child,  16  months.  Marked  toxic  symp- 
toms. Recovery.  Brandy  and  fluid  ex- 
tract of  digitalis  frequently  repeated  in 
spite  of  vomiting.  Byron  F.  Dawson 
(Med.  and  Surg.  Reporter,  vol.  Ixii,  p.  7, 
'90). 

Case  7.  Tincture,  2  drachms.  Death. 
Benjamin  Edson  (N.  Y.  Med.  Record,  vol. 
xxxviii,  p.  365,  '90). 

Cases  8,  9,  and  10.  Dr.  Edson  men- 
tions certain  other  cases  known  of,  but 
not  treated  by  him,  three  of  which  died. 

The  amounts  taken  in  these  were  from 
1  to  4  drachms. 

Case  11.  Tincture  (B.  P.),  1  ounce. 
Death  in  sixty-five  minutes.  Mustard, 
lavage,  heat,  ether,  and  brandy  subcu- 
taneously.  L.  M.  Whannel  (Brit.  Med. 
Jour.,  vol.  ii,  p.  791,  '90). 

Case  12.  Fleming's  tincture,  1  drachm. 
Recovery.  Sulphate  of  zinc,  tincture 
of  digitalis,  20  minims  hypodermically. 
Whisky,  1  ounce,  by  the  mouth,  followed 


ACONITE.    THERAPEUTICS. 


105 


by  calomel,  8  grains.  L.  M.  Whannel 
(Brit.  Med.  Jour.,  vol.  ii,  p.  791,  '90). 

Case  13.  Fleming's  tincture,  1  tea- 
spoonful.  Recovery.  Mustard,  spirit  of 
ammonia  comp.  (B.  P.),  tincture  of  bella- 
donna, brandy.  T.  F.  H.  Smith  (Brit. 
Med.  Jour.,  vol.  i,  p.  1109,  '93). 

Case  14.  Fluid  extract,  4  drachms. 
Recovery.  Emetics,  atropine  and  brandy 
subcutaneously.  Henri  E.  R.  Altenloh 
(N.  y.  Med.  Jour.,  vol.  Ixvii,  p.  358,  '93). 

Case  15.  Tincture,  7  7=  drachms.  Re- 
covery. Mustard,  digitalis,  and  brandy 
subcutaneously;  digitalis,  nux  vomica 
and  brandy  by  rectum;  ether  and  am 
monia  by  inhalation;  brandy  and  am 
monia  carbonate  by  mouth  later.  G.  H 
Tuttle  (Boston  Med.  and  Surg.  Jour, 
vol.  XXV,  p.  678,  '91). 

Case  16.  Mentioned  by,  but  not  seen 
by.  Dr.  Tuttle.  Tincture,  5  7:  drachms. 
Death.  G.  H.  Tuttle  (Boston  Med.  and 
Surg.  Jour.,  vol.  xxv,  p.  678,  '91). 

Case  17.  Preparation  not  noted.  Four 
teaspoonfuls.  Recovery.  Sulphate  of 
copper,  digitalis,  wine  by  mouth ;  whisky 
by  rectum ;  whisky,  7=5  grain  sti-ychnine, 
and  digitaline,  7ki  grain,  hypodermically. 
M.  A.  Warriner  (N.  Y.  Med.  Record,  vol. 
xxxix,  p.  521,  '91). 

Case  18.  Tincture,  2  drachms.  Recov- 
ery. Apomorphine,  stomach-tube,  tinct- 
ure of  digitalis,  25  minims;  aromatic 
spirit  of  ammonia,  45  minims;  brandy, 
2  drachms  subcutaneously,  heaters,  sina- 
pism to  praecordia.  S.  Q.  Robinson  (Bos- 
ton Med.  and  Surg.  Jour.,  vol.  cxxvii,  p. 
192,  '92) . 

Case  19.  Tincture  (B.  P.),  30  minims. 
Recovery.  Salt  and  water  one  and  a  half 
hours  after  poison.  Sulphate  of  zinc  two 
hours  after  poison.  Charcoal,  brandy, 
and  water  by  mouth.  William  Hard- 
man  (Brit.  Med.  Jour.,  vol.  i,  p.  1320, 
'93). 

Case  20.  Preparation  not  stated.  Five 
drops.  Recovery.  Belladonna  and  stro- 
phanthus,  champagne,  brandy,  heaters. 
J.  D.  Leigh  (Edinburgh  Med.  Jour.,  vol. 
xl,  p.  638,  '95). 

Reported  by  R.  AV.  Greenleaf  (Boston 
Med.  and  Surg.  Jour.,  July  15,  '97). 

Therapeutics. — Aconite  is  mainly  used 
as  an  arterial  sedative.    By  diminishing 


the  force  and  the  rapidity  of  the  heart's 
action,  it  lessens  blood-pressure,  and,  in 
doing  this,  tends  to  allay  spasm  and 
relieve  undue  excitability  of  the  nerve- 
centres.  It  is,  therefore,  indicated  while 
the  pulse  is  high  and  resisting. 

Aconite  causing  increased  perspira- 
tion, it  is  indicated  where,  with  a  high 
pulse,  there  is  dryness  of  the  skin.  The 
evaporation  of  sweat  from  the  surface 
and  the  heat-radiation  due  to  the  in- 
creased peripheral  circulation  resulting 
from  relaxation  of  the  cutaneous  capil- 
laries also  cause  a  reduction  of  temper- 
ature. Aconite  also  possesses  diuretic 
properties.  Hence  it  appears  to  be  en- 
dowed with  all  the  qualities  requisite 
in  the  incipient  stage  of  uncomplicated 
inflammatory  disorders,  as  an  anodyne 
sedative. 

In  children  aconite  may  be  given  when- 
ever the  spasmodic  element  is  clearly 
marked:  in  fever  preceding  attacks  of 
quinsy,  pharyngitis,  etc.;  in  asthma  and 
the  asthmatic  crises  of  bronchial  ade- 
nopathy; in  pertussis  and  other  spas- 
modic coughs;  in  laryngismus  stridulus; 
in  palpitations  associated  or  not  with 
hypertrophy  of  the  heart;  and  in  con- 
vulsions.    (Comby.) 

The  tincture  of  aconite  may  be  used 
with  safety  for  the  reduction  of  the  tem- 
perature when  dangerous  symptoms,  as 
restlessness,     jactitation,     and    delirium 
(which  are  forerunners  of  eclampsia  or 
coma)   are  present.     A  child  of  8  years 
could  take  1  minim,  and  one  of  12  years 
1  7=  minims  every  three  hours.    J.  Lewis 
Smith  (Archives  of  Pediatrics,  Dec,  '91). 
By  reason  of  its  sedative  and  depress- 
ant action  aconite  is  contra-indicated  in 
all  cases  in  which  prostration  exists  or 
threatens.     If  the  respiration  is  embar- 
rassed, if  the  heart  is  in  asystole,  if  the 
patient  is  depressed,  recourse  must  be 
had  to  tonics  and  stimulants.     In  bron- 
cho-pneumonia,   pneumonia    after    the 


106 


ACONITE.     THERAPEUTICS. 


primary  stage,  valvular  affections  of  the 
heart,  and  in  all  cases  of  collapse  occur- 
ring in  acute  infectious  diseases,  aconite 
is  particularly  contra-indicated. 

Fever.  —  The  physiological  effects 
enumerated  afford  sufficient  ground  for 
its  value  in  the  reduction  of  all  the 
phenomena  attending  the  febrile  state: 
high  temperature,  dry  skin,  hard  and 
frequent  pulse,  etc.  The  tincture  is 
preferable  here,  as  it  is  in  all  other 
disorders.  The  best  effects  are  produced 
by  means  of  small  doses.  One  minim  is 
first  given,  then  another  minim  in  one- 
half  hour.  After  that,  ^/a  minim  is  given 
every  half-hour  until  the  febrile  symp- 
toms are  reduced  or  until  physiological 
symptoms  of  the  drug  appear.  Aconite 
should  always  be  greatly  diluted. 

Aconite  is  especially  of  value  in  the 
fever  attending  the  incipient  stage  of 
catarrhal  disorders.  It  may  be  used  as 
an  apyretie  in  continued  fevers  and 
infectious  diseases, — variola,  scarlatina, 
erysipelas,  etc., — but  large  doses  are  usu- 
ally required,  involving  correspondingly 
great  danger. 

In  the  reflex  fever  which  sometimes 
follows  the  use  of  the  catheter  it  is  very 
efficient.     (Wood.) 

DiSOEDEES       OF       THE       ReSPIEATOET 

Teact. — In  acute  disorders  of  the  nose, 
throat,  and  lungs  the  depressing  effects 
exerted  by  aconite  upon  respiration 
through  its  influence  upon  the  respira- 
tory centre  and  upon  the  muscles  con- 
cerned in  respiration  are  added  to  the 
qualities  previously  enumerated.  Hence 
its  value  in  acute  coryza,  pharyngitis, 
tracheitis,  bronchitis,  pleurisy,  and  pneu- 
monia. In  all  of  these,  1  drop  of  the 
tincture  every  hour  should  be  admin- 
istered iintil  the  physiological  effects — 
tingling  and  numbness  of  the  lips  and 
tongue  —  are  experienced,  when  the 
remedy  should  be  given  less  frequently. 


After  the  initial  stage  of  the  affections 
enumerated,  aconite  should  be  discon- 
tinued, especially  in  pneumonia,  in  which 
affection  its  administration  is  positively 
harmful  as  soon  as  the  asthenic  stage 
begins.  In  the  chronic  disorders  of  the 
respiratory  passages — including  phthisis 
— it  is  more  hurtful  than  beneficial. 

Eheumatism.  —  Aconite  is  consider- 
ably used  in  all  forms  of  rheumatism  as 
an  anodyne.  It  is  especially  indicated 
when  the  skin  is  dry.  The  diaphoresis 
resulting  from  its  use,  added  to  its  anal- 
gesic effect,  tend  to  shorten  the  duration 
of  the  disease.  This  is  especially  the 
case  in  the  acute  rheumatic  pains  due  to 
exposure. 

Neuealgia. — In  the  form  of  neural- 
gia characterized  by  exacerbations  dur- 
ing damp  weather  aconite  is  sometimes 
very  effective  in  small  doses  frequently 
repeated.  If  the  painful  spot  does  not 
cover  much  surface,  application  of  the 
tincture  over  it  with  a  camel's-hair 
pencil  contributes  markedly  to  hasten 
the  relief. 

Meningitis,  Pericarditis,  and  Per- 
itonitis. —  These  three  inflammatory 
disorders  of  serous  membranes  are 
mentioned  concurrently  owing  to  the 
fact  that  their  early  manifestations  are 
equally  influenced  by  aconite.  In  peri- 
tonitis especially  its  effect  as  an  anodyne 
tends  to  prevent  vomiting:  an  important 
feature.  In  pericarditis  it  markedly  in- 
creases the  chances  of  recovery  by  re- 
ducing the  number  of  pulsations,  thus 
prolonging  the  resting  periods  between 
beats. 

Cardiac  Disorders.  —  By  lowering 
arterial  tension  and  diminishing  the 
number  of  heart-beats  it  may  be  of 
advantage  in  functional  disorders,  but 
when  organic  lesions  are  present  it  had 
better  not  be  used.  It  is  sometimes  em- 
ployed   in    uncomplicated    hypertrophy. 


ACONITINE.     PHYSIOLOGICAL  ACTION.     POISONING. 


lor 


however,  to  antagonize  exaggerated  ac- 
"tion,  but  its  effects  should  be  closely 
watched  lest  incipient  degeneration  be 
present. 

ACONITINE.  —  Aconitine  is  an  alka- 
loid obtained  from  Aconitum  napellus, 
■and  represents  the  active  principle  of 
■aconite.  It  occurs  in  colorless,  tabular 
crystals,  slightly  soluble  in  water,  but 
.soluble  in  alcohol,  ether,  and  chloro- 
form.    It  is  extremely  poisonous. 

Dose.  —  The  preparations  entitled  to 
•confidence  are  those  of  Merck  and  of 
Duquesnel,  the  latter  especially,  owing 
to  its  constant  strength.  The  German 
preparations  of  aconitine  are  thought  to 
be  impure.  The  dose  is  from  V300  to 
V230  grain. 

The  virulence  of  aconitine  causes  the 
responsibility  of  the  physician  to  be  in- 
volved to  a  greater  degree  than  in  the 
•case  of  other  poisons.  It  should  be  ad- 
ministered in  small  doses  onl}',  if  used 
■at  all. 

Case  of  fatal  poisoning  by  a  single  dose 
of  aconitine  in  France.  Physician  fined 
100  francs.  Editorial  (Gaz.  des  Hop., 
Paris,  Sept.  S,  '91). 

Nitrate  of  aconitine  given  by  practi- 
tioners in  doses  of  V32,  '/22J  and  Vis  grain. 
These  relatively  large  quantities  are  apt 
to  be  followed  by  serious  results.     Edi- 
torial (Medical  Age,  May  25,  '92). 
The  activity  of  aconitine  is  markedly 
increased  when  it  is  administered  hypo- 
■dermically. 

Injections  of  the  alkaloid  in  various 
neuralgias  excessively  painful  and  pro- 
ductive of  toxic  symptoms.  A.  Cohn 
(Deutsche  med.-Zeit,  Oct.  22,  '88). 

From  experiments  on  rabbits  and  dogs 
it  was  thought  that  as  much  as  V3  grain 
of  aconitine  could  be  given  to  the  horse, 
whereas  half  that  dose  would  be  fatal. 
It  is,  therefore,  illogical  to  calculate  the 
toxicity  of  a  poison  by  the  weight  of  an 
animal,  and  still  more  so  to  draw  con- 
clusions as   to  one   species   from  experi- 


ments  on   another.     Aconitine   possesses 
great  activity  when  given  by  hypodermic 
injection.     Weber   (Le  Bull.  M6d.,  Mar. 
20,  '95). 
The  fact  that  the  preparations   dis- 
pensed vary  greatly  in  strength  accord- 
ing to  the  source  of  production  militates 
against  its  use. 

Especial  attention  called  to  the  various 
degrees  of  strength  of  the  several  varie- 
ties  of  aconitine   on   the   market.     The 
division  into  French,  German,  and  Eng- 
lish  aconitine   is   as  unreliable  as   it  is 
unscientific.     William  Murrell    (Medical 
Bulletin,  June,  '90). 
PliysioiOgical  Action.  —  Aconitine  in 
minute  doses  reduces  the  action  of  the 
heart  and  thereby  reduces  arterial  ten- 
sion.   In  large  doses,  or  in  persons  pre- 
senting undue  sensitiveness  to  the  effects 
of  aconite,  this  action  manifests  itself 
more  markedly,  reaching,  in  fatal  cases, 
to  arrest  of  the  heart  in  diastole.    Aconi- 
tine reduces  temperature  by  this  influ- 
ence on  cardiac  action;   it  also  tends  to 
inhibit  respiratory  action  by  its  paralyz- 
ing influence  upon  the  muscles  of  res- 
piration.    On  general  principles,  aconi- 
tine tends  to  reduce  functional  action 
through   its   paralyzing   influence   upon 
nerve-centres. 

Aconitine  Poisoning. — The  symptoms 
following  a  poisonous  dose  are  those  of 
aconite  poisoning,  but  they  occur  more 
rapidly;  hypodermically  administered, 
aconitine  may  cause  death  in  less  than 
a  minute.  Tingling  in  the  mouth  and 
throat,  numbness  of  the  face  and  ex- 
tremities, reduction  of  the  cardiac  pul- 
sations, shallow  breathing,  dilatation  of 
the  pupils,  cold  sweats,  purging,  etc., 
follow  in  quick  succession,  death  com- 
ing on  through  paralysis  of  the  heart. 

Case  of  poisoning  in  which  a  stout 
German  took  eighteen  tablets  of  aconi- 
tine each  containing  '/zoo  grain,  probably 
within  half  an  hour's  time.  One  hour 
and    a    half    afterward    there    appeared 


108 


ACONITINE. 


ACROMEGALY. 


symptoms     of     paraplegia ;      stertorous, 
irregular  respirations,  from   six  to  thir- 
teen  times  a   minute;     strangling;     and 
tingling  in  the  fauces.     Pulse  irregular, 
pupils  slightly  dilated  and  sluggish.    Re- 
covery  under  morphine   hypodermically, 
emetics,  whisky,  and  ammonia.     Valen- 
tine  (N.  Y.  Med.  Jour.,  Dec.  15,  '88). 
Treatment   of  Aconitine  Poisoning. — 
The  general  indication  is  to  prevent  syn- 
cope.   The  recumbent  position,  warmth, 
and  stimulants  are  pre-eminent  among 
the    measures    to    be    employed.      The 
stomach-tube  may  be  used  if  the  heart's 
action  is  not  too  weak,  while  the  stim- 
ulation is  procured  by  hypodermic  in- 
jections of  ether,  ammonia,  or  whisky. 
Strychnine,  digitalis,  or  caffeine  are  also 
valuable,  but  their  action  is  not  as  rapid. 
They  may  be  utilized  to  great  advantage 
to  sustain  the  heart's  action,  however, 
after  the  patient  has  shown  evidences  of 
reaction. 

Case  in  which  Vo  grain  of  crystallized 
aconitine  was  taken  in  mistake;    the  pa- 
tient saved  through  energetic  measures, 
combined   with   large   doses   of  caffeine, 
subcutaneously,    to    sustain    the    heart. 
Veil  (La  France  Med.,  Sept.  29,  '93). 
Therapeutics. — Aconitine  is  possessed 
of  no  advantage  that  the  preparations 
of  aconite  usually  employed  do  not  offer, 
and  is  much  more  likely  to  give  rise  to 
untoward  results.    It  has  been  used  with 
advantage  in  neuralgia  and  pneumonia, 
especially  in  the  broncho-pneumonia  fol- 
lowing upon  influenza.    Erysipelas  seems 
also  to  have  been  successfully  treated 
with  aconitine. 

Treatment  of  eiysipelas  of  the  face  by 
the  use  of  nitrate  of  aconitine  eminently 
successful  in  doses  of  Vp,«  grain  every 
two  hours,  taking  care  not  to  exceed  a 
daily  dose  of  '/„,  grain.  Course  greatly 
lessened  and  great  relief  fi'om  pain. 
Tison  and  Bourbon  (London  Med.  Re- 
corder, Jan.,  '91). 
Spurious  Preparations. — Aconitine  has 
also  been  obtained  from  other  varieties  of 


aconite, — Aconitum  ferox  and  Aconitum 
japo7iicum, — but  the  properties  of  the 
preparations  are  still  insufficiently  known. 

Aconitine  obtained  from  Aconitum 
napellus  possesses  the  same  diaphoretic 
properties  as  pilocarpine.  This  effect  is 
not  obtained  by  the  doses  ordinarily  em- 
ployed. Aconitine  from  Aconitum  ferox 
and  A.  japonicwn  has  no  such  property. 
P.  Aubert  (Pharm.  Centralhalle  fur 
Deutschland,  No.  22,  '94). 

Pseudaconitine,  a  highly  poisonous  con- 
stituent of  the  aconite  found  in  Nepaul, 
probably  Aconitum  ferox.  Small,  color- 
less, transparent,  dextrorotatory  crystals, 
verj'  slightly  soluble  in  water,  readily  in 
alcohol,  chloroform,  and  acetone.  Per- 
sistent tingling  sensation  on  the  tongue; 
slightly  more  toxic  than  aconitine.  W. 
R.  Dunstan  and  Francis  H.  Carr  (Jour- 
nal of  the  Chemical  Society,  p.  3.50, 
'97). 


ACROMEGALY.  — (Greek.)  From 
axpoT,  extremity,  and  ^dyag,  great. 

Definition.  —  A  non-congenital  hyper- 
trophy of  the  bones,  especially  the  su- 
perior, inferior,  and  cephalic  extremities. 
It  was  first  described  by  Dr.  Pierre  Marie, 
of  Paris,  in  1885. 

Symptoms.  —  In  this  disease  there  are 
two  classes  of  symptoms: — 

I.  Constant  or  almost  constant. 

(a)  Hypertrophy  of  the  hands.  This 
is  often  the  first  symptom  noticed.  They 
are  spade-like, — namely,  thick  and  wide, 
without  notable  increase  in  length.  The 
bones,  mitscles,  cellulo-adipose  tissue,  and 
skin  are  all  involved  in  the  overgrowth. 
The  skin  is  not  oedematous,  but  is  firm 
on  pressure  and  somewhat  darkened. 
The  fingers  are  much  enlarged,  sausage- 
like, as  thick  at  the  distal  as  at  the 
proximal  extremities.  The  interphalan- 
geal  furrows  and  the  lines  of  the  palms 
are  exaggerated,  while  the  thenar  and 
hypothenar  eminences  are  enlarged.  The 
finger-nails  seem  short,  widened,  and  are 


ACROMEGALY.  SYMPTOMS. 


109 


usually    striated    longitudinally.       The 
fingers  are  rarely  club-shaped. 

The   hypertrophy    does   not    seem    to 
affect  the  wrist  to  the  same  dee-ree  as  it 


Typical   hand   in  advanced  acromegaly. 
(Gaston  and  G.  Brovardel.) 

does  the  remainder  of  the  forearm  and 
hand.  The  arm  and  forearm,  therefore, 
though  they  may  be  slightly  enlarged, 
do  not  appear  so.  There  is  no  interfer- 
ence with  the  function  of  the  hands. 


Sciagraph  of  the  above  hand,  showing 
hyperostosis. 

(b)  Hypertrophy  of  the  feet.  This  is 
of  the  same  character  as  that  of  the 
hand.?.      They   are   widened,   thickened, 


but  not  lengthened,  and  the  hypertrophy 
ceases  or  appears  to  cease  at  the  ankles. 
(c)  Hypertrophy  of  the  head.  The 
skull  is  slightly  increased  in  size,  hut  the 
face  is  much  more  affected:  it  is  length- 
ened; the  eyes  seem  small  compared  to 
the  size  of  the  eyelids  and  orbital  bor- 
ders; the  nose  is  enormous  and  flattened; 
the  cheek-bones  and  chin  project  and  the 
lips  are  much  thickened.  The  lower 
jaw-bone  is  especially  affected.  The 
tongue  is  increased  in  size  and  may  even 


Case  showing  typical  hypertrophy  of  the 
feet.      (Gifford.) 

protrude  from  the  mouth  and  greatly  in- 
terfere with  speech.  The  hard  and  soft 
palate,  the  uvula,  the  tonsils,  the  pillars, 
and  even  the  teeth  may  be  enlarged, 
causing  cough  and  difficulty  in  speaking 
and  eating. 

Case  with  marked  hypertrophy  of  the 
scalp.  Hutchinson  (Archives  of  Surg., 
Oct.,  '89). 

Case  in  which  trophic  lesion  was  anal- 
ogous to  acromegaly;  chief  symptom 
was  gradual,  progressive  enlargement  of 
head  and  neck.     Denomination  of  "me- 


110 


ACROMEGALY.  SYMPTOMS. 


galocephaly"  proposed.  M.  Allen  Starr 
(Amer.  Jour.  Med.  Sci.j  Dec,  '94). 
(d)  Thorax.  The  vertebras  are  espe- 
cially affected,  causing  cerTico-dorsal 
kyphosis,  which  may  coincide  with  lum- 
bar lordosis.  The  h3'pertrophy  of  the 
sterniTm,  clavicles,  ribs,  costal  cartilages, 
and   scapula;   causes  the   chest  to   seem 


Cheyne-Stokes  variety,  and  inability  to- 
retain  either  food  or  drink  in  his  stom- 
ach. Enlarged  pituitary  body  found  at 
the  post-mortem.  The  gland  weighed 
475  grains,  instead  of  5  to  10  in  the  nor- 
mal condition.  J.  E.  Rathmell  (Southern 
Practitioner,  Dec,  '95). 
(e)  Headache  is  often  one  of  the  first 
symptoms.      It    may   be    continuous    or 


Case  showing  characteristic  alterations  of  the  thorax.     (Fritscli,  Elebs,  and  Brlgldi.) 


flattened  from  side  to  side  and  increased 
in  depth  from  behind  forward.  The  de- 
formity of  the  chest  may  make  respira- 
tion difficult  and  cause  it  to  become 
abdominal  in  type. 

Uncommon  symptoms:    long-continued 
abnormal  rhythm  in  respiration   of  the 


paroxysmal,  diffuse,  or,  as  is  more  fre- 
quent, localized  in  the  occiput  or  nape 
of  the  neck. 

Two  cases,  one  of  which  had  suffered 
temporarily  from  exceedingly  acute 
cephalalgia.  Kalindero  (Rev.  Inter,  de 
Med.  et  de  Chir.,  Oct.  25,  '94) . 


ACROMEGALY.     SYMPTOMS. 


Ill 


(/)  Amenorrhoea  resulting  in  sterility 
is  one  of  the  first  symptoms  in  women. 

In  two  women  premature  cessation  of 
menses  and  hypertrophy  of  pituitary 
body.  Ransom  (Brit.  Med.  Jour.,  June 
8,  '95). 

Case  appearing  at  47  years;  amenor- 
rhcea  was  only  transitory,  and  menstru- 
ation was  normal.  Thomas  (Revue  M6d. 
de  la  Suisse  Rom.,  June  20,  '93). 

II.  Secondary  symptoms: — 
The  neck  is  often  short  and  thick. 
The  thyroid  gland  may  be  normal, 
atrophied,  or  increased  in  size.  The 
larynx  is  usually  enlarged,  causing  in 
women  a  low  voice  and  dyspnoaa.  The 
nasal  cavities  may  also  be  compromised 
by  enlargement  of  the  turbinated  bones, 
another  source  of  dyspnoea  being  thus 
afforded. 

Case  of  acromegaly  complaining  of 
pain  in  the  left  side  of  the  nose  and 
slight  difficulty  in  breathing.  The  in- 
ferior turbinated  bodies  were  enormously 
enlarged;  the  other  structures  in  the 
nasal  cavity  appeared  normal.  The  an- 
terior and  posterior  pillars,  the  soft 
palate,  and  the  uvula  were  much  thick- 
ened; also  the  tonsils  and  their  capsules. 
The  lingual  glands  were  much  hyper- 
trophied.  An  external  examination 
showed  that  the  larynx  was  very  much 
enlarged.  The  epiglottis  was  thickened. 
The  arytenoid  cartilages  and  the  ven- 
tricular bands  were  enlarged.  The  glottis 
was  very  small.  While  the  patient  re- 
mained quiet,  respiration  was  only 
slightly  impaired,  but  excitement  pro- 
duced labored  breathing  and  a  crowing 
sound  during  both  expiration  and  in- 
spiration. During  one  of  these  attacks  of 
dyspnoea  the  patient  died.  W.  F.  Chap- 
pel  (Amer.  Medieo-Surg.  Bull.,  Jan.  18, 
'96). 

Case  in  which,  besides  other  typical 
symptoms,  the  cartilages  of  the  nose  and 
ears  were  greatly  thickened,  and  prob- 
ably those  of  the  larynx,  as  his  voice  had 
altered  of  late  to  a  deep  bass.  The  skin 
of  the  face  was  slightly  pigmented;  the 
orifices  of  sweat-glands  enlarged.  The 
tongue    was    enlarged    enormously,    the 


tonsils  and  uvula  also.  Difficulty  in 
swallowing  at  times  and  slight  asthmatic 
seizures.  John  N.  d'Esterre  (Brit.  Med. 
Jour.,  Dee.  4,  '97). 

In  women  the  mammse  are  atrophied, 
the  abdomen  is  enlarged  and  pendulous, 
and  the  pelvis  and  external  genitalia  en- 
larged and  thickened.  The  uterus  may 
be  atrophied. 

In  man  the  penis,  scrotum,  and  tes- 
ticles may  be  enlarged  or  diminished. 
Sexual  power  and  feeling  may  be  abol- 
ished. 

Case  of  acromegaly  of  fourteen  years"^ 
standing  in  which,  although  the  patient 
is  52  years  old,  there  is  no  impediment 
of  the  sexual  function.  J.  R.  Rathmell 
(Southern  Practitioner,  Dec,  '95). 

The  muscular  system  is  usually  atro- 
phied, though  it  may  be  normal  or  hy- 
pertrophied.  Electrical  excitability  is- 
diminished  (Erb)  or  increased  (Ver- 
straeten). 

Case  with  amyotrophy,  which  appeared 
to  be  due  to  compression  of  the  rachidian 
nerves.    Duchesneau  (Thfese  de  Lyon). 
Some  articulations  (knee,  wrist)  have 
been  found  enlarged  and  giving  creak- 
ing sounds  on  movement,  owing  to  re- 
laxation of  the  ligaments. 

Case  in  which  there  were,  with  great 
deformity  of  wrists,  trophic  lesions  of  the 
joints, — a  certain  amount  of  muscular 
atrophy  similar  to  that  occurring  in  the 
progressive  atrophy  of  Duchenne.  There 
were  also  a  few  symptoms  of  Raynaud's 
disease  and  a  trace  of  albumin  in  the 
urine.  Middleton  (Glasgow  Med.  Jour., 
June,  '94). 

Case  in  which  there  was  a  cystic  tumor 
in  the  popliteal  space,  communicating- 
with  the  joint;  in  the  latter  were,  be- 
sides synovial  fluid,  five  small,  solid 
masses.  Roswell  Park  (Inter.  Med.  Mag., 
July,  '95). 

The  knee-jerk  is  not  increased;  it  may 
be  normal,  decreased,  or  absent.  Car- 
diac hypertrophy  with  palpitation  some- 
times   occurs.      Arterial    sclerosis    and' 


112 


ACROMEGALY.     SYMPTOMS. 


varicose  veins  have  been  noted.  Hy- 
pertrophy of  the  lymphatic  vessels  and 
glands  is  not  very  infreqvTent. 

Hunger  and  thirst  are  usually  in- 
creased. Sometimes  there  is  dyspepsia. 
Duchesneau  records  enteroptosis  and 
nephroptosis. 

Polyuria,  glycosuria,  peptonuria,  and 
phosphaturia  have  been  noted.  Occa- 
sionally there  is  excessive  sweating. 

Case  of  acromegaly  with  Graves's  dis- 
ease and  glycosuria.  Lancereaux  (La 
Sem.  Mgd.,  Feb.  16,  '95). 

Case  of  acromegaly  in  which  there 
were,  besides  sarcoma  of  the  hypophysis 
cerebri,  diabetes  and  struma.  Hanser- 
mann  (Berliner  klin.  Woch.,  May  17, 
'97). 

Case  of  acromegaly  in  a  man  37  years 
of  age  in  which  there  was  also  aliment- 
ary glj'cosuria,  peculiar  joint  swellings, 
and  paroxysmal  hsemoglobinuria.  The 
joint  swellings  were  probably  of  trophic 
and  vasomotor  origin.  The  paroxysmal 
hsemoglobinuria  was  probably  dependent 
upon  alterations  in  the  vessels,  almost 
constantly  found  in  acromegaly,  and  a 
causative  role  in  the  production  of  this 
disease.  It  is  probable  that  the  hypoph- 
ysis secretes  a  substance  that  influ- 
ences the  heart  and  vasomotor  system. 
Chvostek  (Wiener  klin.  Woch.,  Nov.  12, 
'99). 

Frequent  observance  of  the  coincidence 
of  sugar  in  the  urine  in  cases  of  acrome- 
galy. Three  eases:  one  of  genuine  dia- 
betes mellitus,  one  of  polyuria  in  which 
the  sugar  gradually  disappeared  after 
great  variations  in  its  percentage,  and 
one  of  alimentary  glycosuria.  The  last 
case  attributed  to  a  tumor  of  the  hy- 
pophysis. W.  Schlesinger  (Wiener  klin. 
Kund.,  Apr.  15,  1900). 

Analgesia  and  ansesthesia  of  the  skin 
have  been  reported  and  abdominal  pain 
and  great  sensitiveness  to  cold.  The 
skin  is  yellowish-brown  and  darkest  at 
the  extremities.  It  is  dry  and  wrinkled. 
Warts  are  frequent.  The  hair  is  thick 
and  abundant.  The  body-hair  is  thick 
and  stiff. 


Taste,  smell,  and  hearing  may  be 
affected;  but,  above  all,  vision.  There 
may  be  amblyopia  due  to  papillary  con- 
gestion, irregular  contraction  of  the  field 
of  vision,  and  Argyll  Eobertson's  pupil. 
Especially  interesting  is  temporal  hemi- 
opia  caused  by  pressure  from  the  en- 
larged pituitary  body. 

Case  in  which  there  was  rotatory  nys- 
tagmus, bitemporal  hemianopsia,  and 
atrophy  of  the  optic  nerves.  Reinhold 
Bolty  (Deutsche  med.  Woch.,  July  7, 
'92). 

Case  beginning  in  the  twenty-fifth 
year.  Five  years  later  there  was  atro- 
phy of  both  disks  with  complete  blind- 
ness in  one  eye  and  diminished  vision  in 
the  other.  The  thyroid  could  not  be  felt. 
Dresehf eld  (Brit.  Med.  Jour.,  Jan.  6,  '94) . 
Thickening  of  eyelids,  prominence  of 
orbital  ridges,  exophthalmia,  periorbital 
pains,  hypersecretion  of  tears,  nystag- 
mus, etc.,  have  been  observed.  Hertel 
(La  Presse  Mgd.,  July  13,  '95). 

The  following  eye-symptoms  have  been 
noted  by  Maisonneuve:  Exophthalmos; 
long,  thick,  bronzed  upper  eyelids;  pupils 
reacting  slowly  to  light,  normally  with 
accommodation.  The  movements  of  the 
eyes  are  slow,  and,  in  raising  them,  there 
is  a  want  of  synchronism  with  move- 
ments of  the  lids.  There  is  retinal  en- 
gorgement. 

Case  in  which  the  visual  fields  at  no 
time  showed  any  tendency  toward  the 
hemianopsic  type  which  has  so  often 
been  noted.  This  defect  of  vision  is,  in 
all  probability,  due,  in  most  cases,  to 
pressure  exerted  by  the  hypertrophied 
hypophysis  cerebri.  The  claim  that  this 
pressure,  as  almost  universally  stated,  is 
exerted  upon  the  posterior  border  of  the 
optic  chiasm  is  certainlj'  incorrect. 

In  spite  of  the  gloomy  prospect  for 
good  vision,  which  the  case  at  one  time 
presented  after  more  than  a  year  the 
sight  was  ™/3o  with  each  eye,  and  it  con- 
tinues to  be  good.  Current  accounts 
would  lead  one  to  expect  progressive, 
optic  nerve-atrophy,  ending  in  blindness, 
in  all  cases  where  serious  disturbance  of 


ACROMEGALY.    SYMPTOMS.    DIAGNOSIS. 


113 


the  sight  has  set  in.    H.  Gifford  (West- 
ern Med.  Review,  June  15,  '97). 

There  is  general  muscular  weakness, 
and  the  patients  are  melancholy  and 
irritable.  The  intelligence  remains  un- 
changed in  the  majority  of  cases. 

Case  ot  married  woman,  68  years  old, 
who  first  manifested  signs  of  mental  de- 
fect at  age  of  50  and  was  talcen  to  lios- 
pital  for  insane  because  of  homicidal 
tendencies.  Meanwhile  the  extremities 
became  much  enlarged,  lingers  sausage- 
shaped,  featvires  thickened,  bones  of 
chest  thickened  and  enlarged,  thyroid 
small,  and  thymus  not  discernible. 
Henry  "Waldo  Coe  (Jour.  Amer.  Med. 
Assoc,  Dec.  3,  '98). 

Diagnosis. — Myxcedema. — In  this  dis- 
ease there  is  simple  oedematous  infil- 
tration of  the  soft  parts,  and  a  round, 
swelled  face  instead  of  the  irregular  face 
obseryed  in  acromegaly. 

Case  in  which  a  feature  of  especial 
importance  was  the  marked  increase  in 
the  bulk  of  the  overlying  tissues,  which 
presented  the  appearance  and  sensation 
of  hard  cedema  exactly  resembling 
myxcedema.  The  treatment  has  been 
solely  by  thyroid  extract,  the  result 
being  an  immediate  and  marked  amel- 
ioration of  the  disease.  C.  L.  Greene 
(Med.  Record,  June  8,  1901). 

Osteitis  Defoemans. — In  osteitis  de- 
formans the  face  is  triangular  with  the 
base  upward;  in  acromegaly  it  is  ovoid 
or  egg-shaped,  with  the  large  end  down- 
ward; in  myxcedema  it  is  round  and  full- 
moon  shaped.    (P.  Marie,  Oskr.) 

Leontiasis  Ossea.  —  In  this  disease 
there  is  hyperostosis  of  the  bones  of  the 
face  and  skull.  The  hyperostoses  of  the 
bones  of  these  regions  form  boss-like 
masses;   the  hands  and  feet  are  normal. 

Elephantiasis.  —  The  elephantiasie 
thickening  is  limited  to  the  skin  and  is 
unilateral. 

Chronic  Eheumatism.  —  In  rheuma- 
tism there  are  characteristic  deformities 


of  the  hands  and  feet,  articular  pains, 
muscular  atrophy,  and  early  impotence. 

Eachitism  and  Lymphatisii  United. 
— Special  deformities,  absence  of  enlarge- 
ment of  lower  jaw,  and  macroglossia. 

Erythkomelalgia.  —  Here  the  soft 
parts  of  the  hands  and  feet  are  red,  the 
face  is  unaffected,  and  there  is  no  in- 
volvement of  the  bones. 

Gigantism.  —  In  true  gigantism  the 
body  grows  symmetrically.  In  acro- 
megaly the  abnormal  development  is 
promiscuously  localized.  Gigantism  and 
acromegaly  may,  however,  be  present  in 
the  same  case. 

Acromegaly  may  be  regarded  as  a  par- 
tial giant-growth,  but  it  differs  very 
essentially  from  the  latter.  In  gigan- 
tism the  length  of  the  body  is  over  six 
times  the  length  of  the  foot;  in  acrome- 
galy it  is  under  six  times  the  length 
of  the  foot.  Virchow  (Berliner  klin. 
Woch.,  Feb.  4,  '89). 

Case  of  an  Indian,  exhibited  as  a 
giant,  who  had,  in  addition  to  symptoms 
df  acromegaly,  facial  hemihypertrophy. 
At  the  autopsy  the  pituitary  gland  was 
found  to   be  much  hypertrophied. 

Case  of  another  professional  giant 
seven  feet  and  five  inches  tall,  who  had 
only  some  symptoms  of  the  disease. 
Acromegaly  is  sometimes  associated 
Avith  giant-growth.  Dana  (N.  Y.  Med. 
Jour.,  Aug.  12,  '93). 

Case  in  a  man,  six  feet  and  seven 
inches  in  height.  Another  case  cited, 
height  seven  feet  and  four  inches,  in 
which  there  was  hemihypertrophy  of 
the  face,  on  the  left  side.  This  is  a  rare 
combination,  being  only  the  eleventh 
known.  Dana  (Jour,  of  Nervous  and 
Mental  Dis.,  Nov.,  '93). 

Case  of  acromegaly  in  a  giantess. 
Byrom  Bramwell  (Edinburgh  Med 
Jour.,  Jan.,  '94). 

Autopsy  on  a  giant  from  Egypt,  show- 
ing exosto-ses  and  diffuse  porous  osteo- 
periostitis. Sirena  (La  Med.  Mod.,  July 
18,  '94). 

Autopsy  on  a  German  giant  who  had 
not   begun   to   grow   abnormally   before 


114 


ACROMEGALY.     ETIOLOGY.    PATHOLOGY. 


the  age  of  36  years.  Fritsch  and  Klebs 
(Corres.  f.  Sehweizer  Aerzte,  p.  662,  '93). 
[In  both  cases  there  was  acquired 
gigantism,  which  is  the  most  common 
form.  It  would  seem  that  gigantism,  as 
well  as  dwarfism^  arises  from  a  disease 
occasioning  disturbances  of  growth,  and 
that,  owing  to  the  osseous  lesions  fre- 
quently present,  there  is  a  certain  anal- 
ogy with  acromegaly.  Unilateral  hyper- 
trophy of  the  face  is  of  rare  occurrence. 
P.  SoLLiER,  Assoc.  Ed.,  Annual,  '95.] 

Pulmonary  Osteoarthropathy.  — 
In  this  disease  there  is  hypertrophy  with 
deformities,  but  of  the  osseous  system 
only;  no  amenorrhoea  nor  enlargement 
of  lower  jaw.  The  third  phalanx  of  the 
fingers  is  much  enlarged,  like  a  drum- 
stick, the  nails  are  lengthened,  widened, 
striated  longitudinally,  curved  over  the 
finger-tip.  The  carpus  and  metacarpus 
are  almost  normal,  while  the  wrist  is  en- 
larged and  deformed.  The  same  lesions 
occur  at  the  feet,  and  the  lower  portion 
of  the  leg  may  be  larger  around  than  the 
calf.  The  long  bones,  especially  of  the 
leg  and  forearm,  are  enlarged.  The 
joints  are  swelled  and  move  with  diffi- 
culty. Kyphosis  exists,  when  present, 
only  in  the  lower  dorsal  or  lumbar  re- 
gion. The  face  is  normal,  except  that 
the  upper  jaw-bone  may  be  enlarged. 
Some  chronic  thoracic  lesion  is  present. 
(Marie.) 

Case  presenting  certain  features  like 
those  occurring  in  hypertrophic  pneumic 
osteoarthropathy.  Lavielle  (Jour,  de 
Med.  de  Bordeaux,  Jan.  7,  '94). 

Pulmonary  osteoarthropathy  may  give 
rise  to  some  little  difficulty  in  diagnosis, 
principally  owing  to  its  rarity.  It  is 
most  likely  to  be  confounded  with  acro- 
megaly, but  in  the  latter  disease  there  is 
no  alteration  of  the  nails  nor  are  the 
finger-ends  nor  the  carpus  and  meta- 
carpus much  thickened.  The  chief  char- 
acteristics of  the  disease  are  great  en- 
largement of  the  hands,  wrists,  feet,  and 
ankles,  associated  with,  and  secondary 
to,   some   chronic    pulmonary   affection, 


such  as  phthisis,  chronic  bronchitis,  and 
empyema.  In  the  joints  the  changes  are 
effusion  with  enlargements  and  ulcera- 
tion of  the  cartilages  and  articular  ends 
of  the  bones.  Marie  is  of  the  opinion 
that  these  changes  are  due  to  toxic  poi- 
soning, but  Thorburn  looks  on  them  as 
tuberculous.  The  evidence  either  way  is 
slight  and  indefinite.  G.  A.  Bannatyne 
(Laneet,  Feb.  23,  1901). 

It  is  doubtful  where  acromegaly  can 
be  separated  from  pulmonary  osteoar- 
thropathy.   (Arnold.) 

PSEUDOACROilEGALIC  SYRINGOMYELIji . 

— ASects  usually  the  lower  limbs  only, — 
one  only  sometimes,  and  may  not  affect 
all  the  fingers.  Deformities  and  trophic 
changes  are  present.  Scoliosis  and  dis- 
sociation of  sensibility  are  notable  feat- 
ures. 

Case  of  hereditary  syphilis  presenting 
great  length  of  diaphysis  of  long  bones, 
wrist,  and  elbow.     Nobl   (Le  Bull.  M6d., 
Aug.,  '95). 
Etiology. — The  disease  usually  begins 
between  the  ages  of  20  and  40  years.    It 
is  more  common  in  women  than  in  men, 
and  no  influence  can  apparently  be  at- 
tributed to  race,  heredity,  or  antecedents. 
Case    in    a    woman    aged    63    years. 
Ganse    (Deutsche    med.    Woch.,    Oct.    6, 
'92). 

Case  in  a  young  negro  aged  10  years. 
Beavan  Rake  (Brit.  Med.  Jour.,  Mar.  U, 
'93). 

Cases  of  acromegaly  in  father  and  son. 
In  the  latter  a  tumor  of  the  pituitary 
body  was  found  at  the  autopsy,  together 
with  generalized  endarteritis  and  scle- 
rotic atrophy  of  the  thyroid  gland. 
Bonardi  (Revue  des  Sci.  Med.  en  France 
et  a  I'Etranger,  Jan.  16,  '94). 

Case  following  excessive  weakness  due 
to  parturition.  Middleton  (Glasgow 
Med.   Jour.,  Aug.,   '95). 

Case   suggesting   influence   of  trauma- 
tism   upon    development    of    acromegaly 
and  diabetes.    Marinesco  (Le  Bull.  Med., 
June  26,  '95). 
Pathology. — The  skull  may  show  dis- 
appearance  of  sutures,   hypertrophy   of 


ACROMEGALY.     PATHOLOGY. 


115 


the  external  occipital  protuberance,  de- 
formity of  the  condyles,  thickening  of 
the  frontal  and  occipital  bones,  and  in- 
crease in  size  of  the  processes  inside  the 
skull  and,  above  all,  of  the  pituitary 
fossa.  Both  maxillaries  are  enlarged,  the 
lower  especially  so;  the  alveolar  processes 
and  zj'gomatic  arch  are  also  increased  in 
size. 

Sciagraph  from  a  case  of  Dr.  Sanger 
Brown's.  The  skin  outlines  are  entirely 
lost;  pointed  chin  shows  striking  prog- 
nathous type.  The  light  area  above  the 
upper  teeth  is  the  antrum,  distinctly 
bordered  bj'  an  upper,  bony  plate.  The 
outlines  of  the  orbit  are  not  shown.  In 
normal  cases  the  orbital  arch  shows  itself 
almost  as  this  region  appears  when  a 
skull  is  viewed  laterally.  The  frontal 
eminences  protrude  strongly.  The  light, 
semilunar  area  is  not  the  frontal  sinus, 
which  often  shows  in  sciagraphs,  but  is 
probably  due  to  a  more  membranous 
bony  formation  than  the  outside  layers. 
O.  L.  Schmidt  (Medicine,  July,  '97). 

In  the  vertebral  column  the  hyper- 
trophy especially  affects  the  extremities 
of  the  cervico-dorsal  spinous  processes. 
The  hypertrophy  especially  affects  the 
bones  of  the  extremities  and  the  extremi- 
ties of  the  bones  (Marie). 

There  is  dilatation  of  the  air-sinuses 
of  the  skull,  and  changes  in  the  temporo- 
maxillary  articulation,  permitting  for- 
ward dislocation  of  the  lower  jaw.  There 
is  a  tendency  to  formation  of  new  bone, 
both  in  normal  and  abnormal  situations. 
Thompson  (.Jour,  of  Anat.  and  Phys., 
July,  '90). 

The  most  characteristic  lesion  is  a 
symmetrical  thickening,  which  increases 
toward  the  projections.  Arnold  (Bei- 
triige  z.  path.  Anat.  u.  z.  Allge.  Path., 
B.  10,  No.  1). 

Histologically  the  growth  consists  in 
an  hypertrophy  of  the  medullary  bone, 
while  the  periosteal  bone  is  reduced  to  a 
thin  layer.  This  attacks  red  marrow- 
bones especially.  Duehesneau  (Th6se  de 
Lyon,  '91). 

Case  of  a  young  man  who  entered  the 


hospital  for  a  tumor  of  the  right  thigh, 
requiring  amputation  of  the  limb.  The 
tumor  was  a  malignant  osteoid  growth  of 
J.  Miiller  or  chondrosarcoma  of  Virchow. 
The  patient  had  recovered  from  the 
operation,  which  had  been  performed  in 
December,  1894,  when  thoracic  disturb- 
ances and  symptoms  of  acromegaly  de- 
veloped progressively.  Death  occurred 
toward  the  end  of  September,  1895.  The 
lungs  and  pleurae  contained  enormous 
enchondromatous  tumors,  as  large  as  a 
child's  head  in  some  cases;  microscopic- 
ally they  were  found  to  be  everywhere 
composed  of  cartilage- tissue  at  every 
period  of  development. 


Sciagraph  of  skull  in  acromegaly. 
{Soliviidt.) 

The  pathological  lesions  of  acromegaly 
existed  in  the  limbs;  the  hyperplasia  of 
the  periosteum,  instead  of  being  limited 
to  the  extremities  of  the  phalanges,  e.x.- 
tended  the  entire  length  of  the  limbs  to 
the  hips.  The  shafts  of  the  femur  and 
humerus  were  surrounded  throughout 
their  entire  length  by  osteophytes;  on 
the  ulna  and  radius  some  of  the  osteo- 
phytes could  still  be  compressed  by  the 
finger.  The  epiphyses  Avere  normal,  but 
were,  from  the  youth  of  the  patient,  not 
yet  connected  to  the  shaft.  The  condi- 
tion of  the  pituitary  body  was  not  given 
in  the  autopsy.  In  its  neighborhood,  at 
the  spheno-oecipital  synchondrosis,  a 
myxomatous  enchondrosis  was  found.    R. 


116 


ACROMEGALY.    PATHOLOGY. 


Virehow   (Berliner  klin.  Woch.,  Dec.  16, 

'95). 

Hyperplasia  of  the  connective  tissue 

and  adipose  tissue  of  the  periosteum  is 

present,  while  its  inner  layer  gives  rise 

to  osseous  neoformation. 

There  is  central  absorption  due  to 
osteoblasts,  with  intense  peripheral  his- 
togenesis, in  the  periosteum  and  articu- 
lar cartilage.    (Marie  and  Marinesco.) 

The  lesion  most  frequently  observed, 
and  apparently  the  main  feature  of  the 
disease,  is  one  of  the  pituitary  body. 
This  organ  may  undergo  various  patho- 
logical changes,  ranging  from  hyper- 
trophy to  the  more  malignant  forms  of 
neoplasm,  such  as  sarcoma. 

Of  19  published  eases  there  was  hyper- 
trophy of  hypophysis  in  3,  hypertrophy 
with  increase  of  connective  tissue  in  1, 
sarcoma  in  3,  adenoma  in  2,  softened  ade- 
noma in  1,  tumor  with  little  cavities 
lined  with  epithelium  in  1,  glioma  in  1, 
tumor  with  character  not  specified  in  3, 
vascular  hypertrophy  in  1,  colloid  degen- 
eration in  1,  sclerosis  and  atrophy  in  1, 
and  necrosis  with  softening  in  1.  Stem- 
berg  (Zeit.  f.  klin.  Med.,  vol.  xxvii,  p.  86, 
'95). 

Enough  cases  have  been  reported  to 
refute  the  hypothesis  that  the  enlarge- 
ment of  the  hypophysis  cerebri  in  acro- 
megaly is,  like  the  other  hypertrophies, 
merely  a  symptom  of  the  disease.  If 
simple  hypertrophy  were  the  constant 
lesion,  it  might  be  claimed  that  it  was 
a  result  and  not  a  cause  of  the  disease, 
but  it  hardly  needs  argument  to  show 
the  improbability  that  any  one  disease 
would  cause,  in  a  single  organ,  so  many 
and  various  morbid  conditions  as  are 
enumerated  in  Sternberg's  list.  W.  L. 
Worcester  (Boston  Med.  and  Surg.  Jour., 
Apr.  23,  '96). 

Analysis  of  thirty-four  recorded  ne- 
cropsies on  cases  of  acromegaly.  Changes 
in  the  pituitary  gland  foimd  in  all.  In 
all  but  three  there  had  been  either  hy- 
pertrophy or  tumor.  Percy  Furnivall 
(Lancet,  Nov.  6,  '97). 

Of  97  reported  cases  of  acromegaly, 
autopsy   had    in    15    cases:     12    showed 


changes  in  the  hypophysis  cerebri.  There 
is  a  connection  between  the  changes  in 
the  pituitary  body  and  acromegaly.  Per- 
sonal view  that  all  organs  have  a  double 
function :  a  negative,  withdrawing  some- 
thing from  the  organism ;  and  a  positive, 
introducing  something  into  the  organism. 
The  progressive  development  of  one  or- 
gan has  progressive  development  of  other 
organs  as  a  consequence.  Hansermann 
(Berliner  klin.  Woch.,  May  17,  '97). 

Case  of  acromegaly  in  which  death 
occurred  in  an  accident.  At  necropsy 
the  skull  was  found  uniformly  thickened 
and  heavy,  and  all  the  air-spaces  were 
dilated.  The  sella  Turcica  was  deep  and 
wide,  and  the  pituitary  body  was  con- 
verted into  a  cyst  containing  semifluid 
substance.  Peycy  Furnivall  (Lancet, 
Nov.  6,  '97). 

(1)  Cases  of  acromegaly  associated 
with  true  tumor  of  the  hypophysis  are 
certainly  not  so  numerous  as  has  been 
heretofore  supposed;  (2)  there  is  not  as 
much  constancy  in  the  pathological  con- 
dition of  the  hypophysis  as  there  is  in  the 
enlargement  of  the  heart,  the  thyroid 
gland,  or  the  sella  Turcica;  (3)  acro- 
megaly does  not  depend,  at  least  not 
solely,  upon  abolition  of  any  function  of 
the  hypophysis;  (4)  a  relationship  be- 
tween the  thyroid  gland  and  the  hypoph- 
ysis has  already  been  amply  proved; 
(5)  it  is  not  at  all  improbable  that  pro- 
liferation of  the  histological  elements  of 
the  hj'pophysis  may  be  instituted  in 
some  eases  by  primary  enlargement  of 
the  sella  Turcica;  in  other  eases  an 
oedema  or  hsemorrhage  ex  vacuo;  (6)  we 
have  no  reason  for  supposing  that  en- 
largement of  the  sella  Turcica  must  be  as 
constant  an  occurrence  in  acromegaly  as 
the  changes  in  other  bones,  or  that  it 
might  not  take  place  from  the  same  cause 
or  causes.  Mitchell  and  Lecount  (N.  Y. 
Med.  Jour.,  Apr.  29,  '99). 

Necropsy  of  a  case  in  a  man  who  died 
at  the  age  of  70  and  which  had  the  typ- 
ical characters  of  the  malady.  The  pitu- 
itary body  was  three  times  its  usual  size ; 
the  thymus  was  looked  for  in  vain;  and 
the  thyroid  body  was  goitrous  fibrocystic, 
the  two  lobes — but  especially  the  right — 
being  much  enlarged.  The  heart  was 
large,  without  valvular  lesions;    so  was 


ACROMEGALY.  .  PATHOLOGY. 


117 


the  great  sympathetic;  but  the  diameter 
of  tlie  large  blood-vessels  was  not  sensi- 
bly increased.  Microscopically  the  pitu- 
itary body  showed  in  places  small  colloid 
masses,  a  very  marked  dilatation  of  the 
vessels,  and  hypertrophy  of  the  cells. 
Pagniez  {Bull,  et  Mem.  Soc.  Anat.  de 
Paris,  S.  6,  vol.  i,  p.  942,  1900). 

The  pituitary  gland  as  a  factor  in 
acromegaly  and  giantism:  (1)  the  pitu- 
itary body  is  still  functional;  (2)  dis- 
turbances of  its  metabolism  are  the  prin- 
cipal factors  in  both  acromegaly  and 
giantism,  the  difference  between  the  re- 
sults being  simply  due  to  the  stage  of 
individual  development  at  which  the  dis- 
turbance of  the  function  begins;  (3)  the 
nature  of  the  overgrowth  in  both  these 
diseases  is  primarily  on  the  order  of  a 
pure  functional  hypertrophy,  later,  how- 
ever, losing  some  of  the  definiteness  of  its 
impulse  and  either  producing  immature 
tissue  of  a  mixed  type  or  resulting 
in  simple  hsemorrhagic  exudation,  with 
either  cyst-formation  or  complete  break- 
ing down  of  the  tissue-mass;  (4)  it 
seems  probable,  although  upon  this  head 
the  evidence  is  still  uncertain,  that  some 
part  is  played  by  this  body  in  "dwarf- 
ism," rickets,  and  the  dwarf  forms  of 
cretinism;  (5)  a  reflex  disturbance  of  its 
function  may  possibly  underlie  the  dys- 
trophy accompanying  pharyngeal  ade- 
noids; (6)  it  would  appear  to  be  a  sort 
of  "growth-centre,"  or  proportion-regu- 
lator of  the  entire  appendicular  skeleton. 
Woods  Hutchinson  (N.  Y.  Med.  Jour., 
July  28,  1900). 
The  pituitary  bod}'  is  sometimes  en- 
larged from  the  size  of  a  pigeon's  egg  to 
that  of  a  hen's  egg;  it  dilates  the  pitui- 
tary fossa  and  clinoid  processes,  and  is 
lodged  in  a  considerable  depression  in 
the  base  of  the  brain. 

Case  in  a  woman,  35  years  old,  in 
whom  symptoms  of  confirmed  acrome- 
galy had  been  present  for  three  years. 
In  May,  1893,  there  were  visual  disturb- 
ances, and  double  optic  neuritis  was 
found  to  be  present.  In  July,  1895,  there 
were  noted:  complete  blindness  of  the 
right  eye,  continuous  headache,  and  pain 
in  the  limbs;  the  patient  became  somno- 
lent and  died  in  a  comatose  condition. 


Autopsy  showed  the  thymus  to  be 
abnormallj'  voluminous  and  the  thyroid 
gland  normal.  Some  signs  of  adhesive 
meningitis  were  present  at  the  vertex. 
The  pituitary  body  was  enlarged,  soft- 
ened, and  vascular.  The  dura  mater  of 
the  sella  Turcica  had  disappeared,  and 
the  bone  had  been  worn  away  in  that 
region.  The  hypertrophy  of  the  pitui- 
tary body  had  compressed  the  two  optic 
tracts  and  the  chiasm,  the  right  optic 
tract  being  partly  destroj'ed  and  the  left 
optic  tract  completely  so.  No  other 
lesion  was  found.  The  pituitary  body 
showed,  microscopically,  the  appearance 
of  a  gliosarcoma.  Roxburgh  and  A. 
Collis  (Brit.  Med.  Jour.,  July  11,  '89). 

Case  of  acromegaly  with  post-mortem, 
at  which  the  thymus  was  found  replaced 
by  a  mass  of  fibrous  fat  and  lymphoid 
tissue.  The  thyroid  was  enlarged  sym- 
metrically and  filled  with  small  cysts. 
The  gland-substance  was  normal  under 
the  microscope,  but  there  was  increase  in 
the  interstitial  tissue.  Pituitary  body 
was  enlarged  and  a  portion  of  it  pre- 
sented consistence  and  microscopical  ap- 
pearance of  an  adenoid  tumor.  Pearce 
Bailey  (Phila.  Med.  Jour.,  Apr.  30,  '98). 

Cases  have  been  reported,  however,  in 
which,  although  typical  symptoms  of  the 
disease  were  present,  no  disease  of  the 
pituitar}'  body  could  be  detected. 

Case  with  numerous  cystic  cavities  in 
the  brain,  but  with  a  normal  pituitary 
body.  Waldo  (Brit.  Med.  Jour.,  Mar.  22, 
'90). 

Case  in  a  man,  aged  74  years,  in  whom 
there  was  no  tumor  of  the  hypophysis, 
but  endarteritis  with  atrophy  and  sclero- 
sis of  the  thyroid  body.  Bonardi  (Ri- 
forma  Medica,  Aug.  24,  '93). 

Again,  hypertrophy  of  the  pituitary 
gland  may  not  give  rise  to  the  manifes- 
tations of  the  disease. 

Case  in  which  hypertrophy  of  the 
pituitary  gland  had  caused  no  phenome- 
non of  acromegaly.  Packard  (Amer. 
Jour.  Med.  Sciences,  June,  '92). 

The  pressure  of  the  growths  of  the 
pituitary  body  on  the  optic  tracts  gives 


118 


ACROMEGALY.     PATHOLOGY. 


rise  to  the  oc-ular  disturbances  enumer- 
ated. 

Case  in  which  the  pituitary  body, 
which  was  the  size  of  a  walnut,  was  very 
soft  and  vascular.  The  mass  had  so 
pressed  upon  both  optic  tracts  and  the 
chiasm  as  to  cause  total  disappearance 
of  the  left  tract  and  partial  destruction 
of  the  right.  On  the  left  side  of  the 
mass  there  was  a  blood-clot  the  size  of 
a  large  pea.  Roxburgh  and  Collis  (Brit. 
Med.  Jour.,  .July  11,  '96). 

The  hypophysis  cerebri  generally  lies 
wholly  or  partly  in  front  of,  not  behind, 
the  chiasm,  and  its  anterior  part  is  so 
much   nearer   the  optic  nerves   than  its 
posterior  part  is  to  the  chiasm    (on  ac- 
count of  the  nerves,  chiasm,  and  tracts 
slanting  upward  posteriorly)    that  with 
a  uniform  enlargement  of  the  gland  the 
nerves    in    front    of    the    chiasm    would 
almost   always   be   pressed  upon   sooner 
than  the' chiasm  itself.    Zander  (Deutsche 
med.  Woch.,  vol.  iii,  p.  13,  '97). 
The     nervous     symi^toms     sometimes 
observed  may  also  find  in  the  pressure 
upon    the   surrounding   cerebral   tissues 
one  of  their  causes. 

Case    of   acromegaly    of   many    years' 
standing  in  a  man,  aged  54,  who,  in  the 
last  three  years,  had  developed  Jaekso- 
nian  epilepsy  limited  to  the  right  upper 
extremity    and    right   side    of   the   face. 
Hypertrophy  of  the  pituitary  gland  con- 
stitutes   a    cerebral    tumor    capable    of 
exciting    from    a    distance    the    cortical 
psychomotor     centres.       Raymond     and 
Souques  (Centralb.  f.  Nerv.,  No.  82,  '96). 
The   viscera   may   take   part   in   the 
hypertrophic    process.      The    liver    fre- 
quently shows  fatty  degeneration. 

Case  of  acromegaly  in  which  the  heart 
was  enormously  enlarged,  weighing  two 
pounds  and  nine  ounces:  one  of  the 
largest  hearts  on  record.  0.  T.  Osborne 
(Med.  News,  May  22,  '97). 

Case  of  a  man,  23  years  of  age,  who 
was  quite  well  until  1893,  when  he  had 
an  attack  of  typhoid  fever,  after  which 
typical  acromegaly  developed,  including 
pigmentation,  except  that  there  was  no 
great  enlargement  of  the  lower  jaw.  He 
died,   soon   after   admission,   of   diabetic 


coma.  Necropsy  showed,  in  addition  to 
the  usual  external  signs  of  acromegaly, 
a  general  enlargement  of  the  viscera. 
Liver  weighed  90  ounces,  the  spleen  9  V, 
ounces,  the  heart  13,  and  the  kidney  9. 
The  pituitary  body  was  so  enlarged  as  to 
distend  the  sella  Turcica,  and  contained 
several  drops  of  a  fluid  resembling  pus. 
It  did  not  appear  to  have  compressed 
the  commissure,  and  there  was  no  optic 
atrophy.  Norman  Dalton  (Lancet,  May 
22,  '97). 

The  pigmentation  noticed  in  the  above 
ease  might  have  been  due  to  the  condition 
of  the  thyroid,  the  association  of  acrome- 
galy with   exophthalmic  goitre  being  a 
recognized  one;    the  disease  had  obscure 
relations  with  myxcedema,  and  had  been 
successfully  treated  by  means  of  thyroid 
extract,   although   the   work   of   Schiifer 
and  Oliver  had  shown  that  extracts  of 
thyroid  and  of  pituitary  body  were  an- 
tagonistic   in    action.      H.    D.    Rolleston 
{Brit.  Med.  Jour.,  May  22,  '97). 
The    skin    of   the    extremities    shows 
hyperplasia  of  the  papillse,  and  hyper- 
trophy of  the  derma,  all  the  connective- 
tissue   system  being   enlarged,   that   of 
sweat-glands,     sebaceous    glands,    hair- 
follicles,  external  and  internal  vascular 
walls,    and,    above    all,    the    lamellated 
sheath    of   the    infradermie    nerves    are 
likewise  degenerated. 

There  is  marked  sclerosis  of  the  great 
sympathetic  system,  especially  the  lower 
cervical  ganglion.  The  neuroglia  in  the 
brain  is  hyperplastic. 

Autopsy  showing  following  conditions: 
The  lymphatic  ganglia  of  the  neck  pro- 
foundly altered,  containing  no  more 
lymph-follicles;  all  varieties  of  white 
globules  present,  with  single  nucleus, 
with  polymorphous  nucleus,  and  with 
multiple  nuclei.  The  striated  muscular 
tissue  of  the  neck  show-ed  atrophy  and 
sclerosis,  the  nuclei  had  budded  abun- 
dantly, and  the  sarcoplasma  had  under- 
gone vacuolar  and  granular  fatty  de- 
generation. The  hypertrophied  pituitary 
gland  was  undergoing  process  of  necrosis, 
and  liquefaction  of  its  constituent  parts 
had  taken  place;    the  portions  escaping 


ACROMEGALY.    PATHOLOGY. 


119 


this  destruction  consisted  of  lymphoid 
tissue  similar  to  that  of  the  lymphoid 
ganglia  of  the  neck.  The  thyroid  gland 
was  affected  both  by  atrophy  and  gland- 
ular hypertrophy,  as  well  as  by  hyper- 
trophy of  the  connective  tissue  and 
lymphoid  infiltration. 

The  liver  showed  fatty  degeneration 
and  glandular  atrophy,  with  slight 
lymphoid  infiltration  of  the  interlobular 
connective  tissue.  There  was  chronic 
interstitial  and  parenchymatous  inflam- 
mation of  the  kidneys,  hyperplasia  of 
the  splenic  pulp  and  of  the  Malpighian 
follicles.  The  tongue  was  increased  in 
size  from  hyperplasia  of  its  connective 
tissue.  Claus  and  Van  der  Stricht  (An- 
nales  de  la  Soc.  de  Med.  de  Gand,  No. 
71,  '93). 
The  blood  does  not  show  evidence  of 
great  alteration. 

In  one  case  the  amount  of  htemoglobin 
was   95   per   cent,    of   the   normal;     the 
average  of  ninety-six  countings  showed 
7,000,000    red    corpuscles    to    the    cubic 
millimetre.     The  proportion  of  white  to 
red    corpuscles    was    about    1    to    400. 
Church  and  Hessert  (Med.  Record,  May 
6, '93). 
The  kidnej's  show  chronic  parenchy- 
matons   nephritis   in   the   cortical    sub- 
stance, moderate  sclerosis  of  interstitial 
tissue,  and  peripheral  infarcts. 

In  the  thyroid  gland  the  follicles  are 
either  found  hyperplastic  or  cystic,  and 
contain  hsemoglobin  crystals.  This  organ 
is  generally  hj'pertrophied.  The  thymus 
is  occasionally  found  to  have  persisted. 

Case  showing  a  large  glioma  of  the 
hypophysis,  and  each  lobe  of  the  thy- 
roid enlarged  and  containing  a  cyst. 
Bury   (Med.  Chron.,  July,  '91). 

Typical  case,  which  appeared  to  date 
from  an  old  cerebral  affection,  in  which 
hypertrophy  of  the  thyroid  gland  was 
also  observed.  Bruzzi  (Gaz.  degli  Osp., 
Aug.  4,  '92). 

Case  of  diabetic  acromegaly,  with 
thick  and  heavy  skull,  and  an  occipito- 
frontal diameter  of  sixty-six  centime- 
tres. The  pituitary  body  was  softened 
and  voluminous;  the  thymus  had  per- 
sisted, and  the  thyroid  body  was   cre- 


taceous. Lathuray  (Lyon  M6d.,  .July  11, 
'93). 

Case  with  hypertrophy  of  the  pitui- 
tary body  and  persistence  of  the  thymus; 
the  thyroid  gland  was  enlarged  and 
weighed  nearly  two  ounces.  T.  Coke 
Squance   (Brit.  Med.  Jour.,  Nov.  4,  '93). 

The  thyroid  gland  was  examined  in 
24  cases;  it  was  normal  in  only  5  and 
hypertrophied  in  more  than  half.  The 
thymus  was  examined  in  17  cases;  it 
was  absent  in  7,  hypertrophied  in  3,  and 
persistent  in  7.  The  sympathetic  gan- 
glia were  examined  in  10  cases  and  re- 
ported as  hypertrophied  in  6.  The  only 
constant  associated  changes  appeared  to 
be  those  in  the  pituitary  body;  these 
changes  were  not  uniform  and  might 
occur  without  acromegaly.  Percy  Fur- 
nivall   (Lancet,  Nov.  6,  '97). 

The  spleen  and  the  lymphatic  glands 
are  generally  sclerosed. 

Among  the  various  theories  as  to  path- 
ogenesis of  acromegaly  the  following  are 
the  most  prominent: — 

Acromegaly  is  due  to  an  unusual  de- 
velopment of  the  vascular  system;  it  is 
a  thymic  angiomatosis.  The  endothelial 
elements  originating  in  the  thymus  play 
the  part  of  vasof  ormator  cells,  causing  an 
increase  in  the  vessels,  and  hypernutri- 
tion  and  increase  in  growth  of  the  ex- 
tremities where  the  blood-current  is  the 
slowest.     (Klebs.) 

Case  in  which  there  was  hypertrophy 
of  the  pituitary  body  compressing  the 
optic  nerves,  persistence  of  the  thymus, 
and  hypertrophy  of  the  great  sympa- 
thetic. Cepeda  (Revista  Balear  de  Cien- 
cias  Medicas,  Jan.  15,  '92). 

Case  in  which  the  tumor  of  the  pitui- 
tary body  was  a  typical  spindle-celled 
neurosarcoma. 

The  thymus  was  of  considerable  size, 
but  without  any  change  in  its  elements; 
the  thyroid  gland  was  enlarged  and 
filled  with  small  cysts  containing  col- 
loid matter.  Mosse  and  Daunic  (Soc. 
Anat.,  Paris,  p.  6.33,  Oct.  2.5,  '95). 

It  is  due  to  disturbances  in  the  evolu- 


120 


ACROMEGALY.    PROGNOSIS.    TREATMENT. 


tion  of  the  genital  life.  (Freiind,  Ver- 
straeten.) 

A  trophoneurotic  afEection,  due  to 
changes  in  the  central  and  peripheral 
nervous  system,  causing  hypertrophy  of 
the  extremities  by  means  of  the  vaso- 
motor system.  (Eecldinghausen  and 
Holschewnikow.) 

A  systematic  dystrophy,  something 
like  myxoedema,  and  connected  with 
some  organ  (pituitary  body?)  much  as 
myxffidema  is  in  connection  with  re- 
moval or  alteration  of  the  thyroid  gland. 
(P.  Marie.) 

The  pituitary  body  has  been  destroyed 
in  animals  without  causing  acromegaly. 
(Marinesco,  Vassale,  Sacchi.) 

The  cases  described  by  Hagner,  Fraent- 
zel,  and  Gombault -Marie  must  be  con- 
sidered as  a  form  standing  between 
acromegaly  and  osteoartliropathy.  Tlie 
disease  begins  in  youth,  without  being 
preceded  by  any  affection  of  the  lungs; 
the  bones  of  the  face  arid  the  cartilages 
are  affected,  and  the  pathological 
changes  are  more  lilce  those  of  acrome- 
galy than  of  osteoarthropathy.  F.  R. 
Walters  (Progres  Med.,  No.  3,  '96). 

Three  eases  of  acromegaly,  in  the 
first  of  which  diabetes,  gigantism,  and 
splanehnomegaly  were  present;  in  the 
second  arteriosclerosis,  and  in  the  third 
dyspepsia  and  a  lesion  of  the  pituitary 
body  (sarcoma,  cysts)  ;  but  other  quite 
different  changes  were  likewise  visible, 
namely:  degeneration  of  the  thyroid 
gland,  periependymatous  gliomatosis, 
and  cancer  of  the  viscera. 

When  the  embryological  and  anatom- 
ical relations  of  the  ependyma  and  pitui- 
tary body  are  considered,  it  may  be 
asked  whether  they  do  not,  as  a  whole, 
form  an  anatomical  and  physiological 
system  governing  the  processes  of  nutri- 
tion and  capable,  when  diseased,  of  giv- 
ing rise  to  the  dystrophic  changes  of 
acromegal}'.  Dallemagne  (Arch,  de  Med. 
Exp.,  No.  7.  '96). 

Prognosis. — Progressive,  slow,  and  in- 
terrupted advance  of  the  disease,  lasting 


from  twenty  to  thirty  years,  and  ending 
in  death  either  by  cachexia,  by  some 
complication,  or,  very  rarely,  by  sudden 
syncope  represent,  in  brief,  the  course 
of  the  vast  majority  of  cases. 

Treatment. — At  present  it  can  be  only 
symptomatic.  The  extracts  of  th3'roid 
gland  and  pituitary  body  will  probably 
prove  useless  as  curative  agents.  Pain 
and  insomnia  are  relieved  by  antipyrine, 
sulphonal,  etc.  Arsenic  has  proved  use- 
ful in  some  cases.  Iron  in  large  doses 
and  hydrotherapy  have  done  some  good 
in  one  case  in  the  hands  of  Brissaud,  and 
ergot  in  those  of  Schwartz. 

Case  of  acromegaly  treated  with  desic- 
cated thyroid  gland  with  good  results. 
Solomon  Soils-Cohen  (Med.  and  Surg. 
Reporter,  May  26,  '94). 

Case  treated  by  extract  of  pituitary; 
no  appreciable  result.  Analogy  between 
mj'xoedema  and  acromegaly  suggesting 
the  thj'roid  gland;  rapid  improvement. 
Caton  .(Brit.  Med.  Jour.,  Feb.,  '95). 

Three  cases  of  true  acromegaly  treated 
with  tabloids  of  the  pituitary  body  of 
sheep.  In  the  first  case  the  headache, 
which  was,  at  times,  exceedingly  violent, 
diminished,  and  recurrence  of  the  head- 
ache coincided  always  with  momentary 
cessation  of  the  treatment ;  in  the  second 
case  the  headache,  pains  in  the  limbs, 
and  parfesthesia  of  the  hands  diminished, 
and  the  tumefaction  of  the  soft  tissues 
was  less.  In  the  third  case,  a  diabetic 
patient,  no  results  were  obtained.  Mari- 
nesco  (Soc.  Med.  des  Hop.,  Nov.  S,  '95). 

De  Cyon  mentions  a  case  of  a  child,  12 
years  of  age,  who  suffered  from  acrome- 
galy. Under  influence  of  treatment  by 
hypophysin  continued  during  six  or 
seven  weeks  the  condition  of  the  patient 
was  much  ameliorated;  weight  fell  from 
121  V:  to  101  V'.i  pounds,  and  circumfer- 
ence of  abdomen  from  44  72  to  31  inches. 
Headaches  had  diminished  in  intensity 
and  in  duration,  pulse  had  become  regu- 
lar, and  intelligence  began  to  awaken. 
Lancereaux  (La  Sem.  Med.,  Nov.  23, '98). 
Case  of  acromegaly  in  a  woman  aged 
42  years  corresponding  in  all  respects  to 


ACROMEGALY. 


ACTINOMYCOSIS. 


121 


the  visual  type  of  the  disease.  The  em- 
ployment of  thyroid  tabloids  produced 
a  persistent  and  decided  improvement. 
Gibson  (Edinburgh  Med.  Jour.,  Dec,  '99 ) . 

Our  knowledge  of  the  fact  that  the 
pituitary  body  is  usually  enlarged  in 
oases  of  acromegaly  is  sufficient  evi- 
dence that  the  gland  is  diseased  and 
that  administration  of  the  dried  pit- 
uitary body  is  indicated  as  much  as 
thyroid  extract  in  cases  of  myxcedema. 
The  pituitary  body  may  be  found  en- 
larged in  other  diseases  than  acro- 
megaly, and  this  may  be  compared  with 
goitre  where  it  exists  without  Graves's 
disease.  The  observations  were  upon 
three  eases.  In  the  first  there  was  lit- 
tle or  no  general  improvement,  but  when 
the  drug  was  stopped  the  patient  always 
requested  that  it  be  continued.  In  the 
second  there  was  marked  improvement 
Avhicli  lasted  over  a  year  and  a  half; 
during  this  time  the  patient  only  suf- 
fered from  headache  once,  and  that  was 
when  the  medicine  was  withdrawn  for 
a  day  and  a  half.  The  third  case  was 
complicated  by  advanced  renal  disease 
and  died  suddenly  from  heart-failure, 
although  he  was  considerably  benefited 
by  drug.  The  administration  of  pit- 
uitary body  had  little  effect  upon  the 
first  case,  but  the  last  two  seemed  to 
be  considerably  benefited  in  their  sub- 
jective symptoms.  Kuh  (Jour.  Amer. 
Med.  Assoc,  Feb.  1,  1902). 

Chaeles  W.  Burr, 

Philadelphia. 

ACTINOMYCOSIS.— Gr.,  axtlc,,  a  ray; 
uvxr,q^  fungus. 

Definition.  —  A  parasitic,  infectious, 
and  inoculable  disease  due  to  the  de- 
velopment of  the  actinomyces,  or  ray- 
fungus.  First  described  in  1877  in  cattle 
by  Bollinger  and  in  man  by  James 
Israel;  it  can  no  longer  be  considered  a 
rare  disease.  From  its  frequent  develop- 
ment in  the  lungs  it  has  often  been  con- 
fused with  tuberculosis. 

Symptoms.  —  The  symptoms  vary  ac- 
cording to   the  locality   of  the   disease. 


The  affection  is  chronic  and  exception- 
ally rapid.  The  granulation  tissue  is 
abundant  and  the  mass  resembles  a 
tumor.  Previous  to  suppuration  it  is 
quite  firm,  and,  if  progressing  rapidly, 
is  surrounded  by  diffuse  oedema.  Pain 
and  tenderness  hardly  ever  exist.  When 
suppuration  occurs  the  mass  increases 
rapidly  in  size. 

Total  of  500  eases  from  literature 
showing  that  the  various  regions  of  the 
body  are  proportionately  the  site  of  the 
disease,  as  follows:  Head  and  neck,  55 
per  cent.:  thorax  and  lungs,  20  per 
cent.;  abdomen,  20  per  cent.;  other 
parts,  5  per  cent.  In  France  the  face 
and  neck  were  affected  in  85  per  cent, 
of  the  66  eases  reported.  Poncet  and 
Berard  (Le  Bull.  Med.,  Aug.  8,  '97). 

Mammary  actinomycosis  may  occur 
in  two  ways:  primary  and  secondary. 
In  the  former  infection  occurs  either 
from  propagation  of  the  actinomycotic 
grains  in  the  milk-duets  or  from  their 
penetration  into  the  tissues  through  a 
continuity  of  the  skin.  Four  eases  of 
the  primary  form  witnessed.  The  sec- 
ondary form  spreads  to  the  mammae 
from  the  lung  (most  frequently)  or 
some  other  organ.  The  disease  is  not 
easy  of  diagnosis,  and  is  liable  to  be 
confused  with  tubercle,  cancer,  inter- 
stitial inflammation,  or  syphilitic  dis- 
ease: and  repeated  microscopical  exam- 
ination of  discharges  or  pieces  of  tissue 
should  be  made.  The  prognosis  in  the 
primary  form  is  good,  but  in  the  second- 
ary form  unfavorable.  Mileff  (Gaz.  d. 
Hop.,  Jan.  1,  1901). 

1.  CuTANEOtrs  Surface. — Usually,  a 
lesion  of  the  skin  is  secondary  to  the 
evolution  of  an  underlying  actinomy- 
cotic tumor,  which,  by  its  growth,  bursts 
through  the  skin.  A  sanguineous  or 
purulent  liquid,  containing  the  charac- 
teristic grains,  issues  from  the  ulcera- 
tions so  formed.  The  grains  are  small, 
opaque,  yellowish-white,  or  yellowish 
masses  aboitt  as  large  as  a  pin-head, 
which  are  composed  of  smaller  grains. 


122 


ACTINOMYCOSIS.     SYMPTOMS. 


measuring  about  one-tenth  of  a  milli- 
metre. These  smaller  grains  are  formed 
by  a  central  mass,  of  interwoven  or 
straight  fibres,  whence  extend  toward 
the  periphery  spoke-like  prolongations, 
with  club-like  terminations.  Earely  the 
affection  may  develop  primarily  on  the 
fingers,  hand,  nose,  or  face.  It  forms  a 
small,  round,  ligneous  mass,  which  may 
soften  in  a  few  weeks,  burst  through 
the  skin,  and  give  a  granulous  and  varied 
pus,  containing  actinomycotic  granula- 
tions. The  border  of  the  granulation  is 
uneven,  violet-hued,  and  undermined. 
Around  the  original  mass  there  arise 
secondary  masses;  so  that  the  entire 
lesion  forms  a  violet-red,  indurated 
patch,  deeply  adherent,  and  somewhat 
resembling  scrofuloderma. 

In  cutaneous  antinomycosis  the  lym- 
phatic ganglia  are  usually  not  enlarged. 
Pain  is,  in  some  cases,  intense;  in  other 
cases  it  is  awakened  only  by  pressure. 

Pathognomonic  spots,  which  are  more 
or  less  deep  in  color  according  as  the 
general  color  of  the  lesion  is  more  or 
less  pronounced.  If  the  general  color  is 
pale,  the  spots  are  bluish-red  or  violet;  if 
the  tint  of  the  mass  is  deeper,  the  spots 
present  a  blackish  or  slate  color.  These 
spots  vary  in  size  from  that  of  a  pea  to 
that  of  a  pin's  head.  They  appear  to 
correspond  to  the  points  at  which  the 
wall  of  the  abscess  is  thinnest,  and  it  is 
here  alone  that  fistulse  form.  Derville 
(Jour,  des  Sci.  Med.  de  Lille,  Aug.  31, 
'95). 

Case  of  actinomycosis  extensively  in- 
volving the  skin  in  a  boy,  aged  13,  whose 
family  lived  over  a  stable-yard,  and  who 
suffered  from  an  apparently  simple  at- 
tack of  serous  pleurisy,  from  which  he  re- 
covered with  marked  retraction  of  the  af- 
fected side.  Shortly  afterward  he  was  re- 
admitted to  a  surgical  ward  on  account  of 
abscesses  over  the  front  of  the  chest  and 
right  hip,  which  were  regarded  as  tuber- 
lous,  and  scraped.  He  returned  to  the 
hospital  seven  months  later  with  a  very 
extensive  tract  of  disease  implicating  the 


skin,  chiefly  on  the  back,  the  most  im- 
portant feature  being  large  sarcomatous- 
looking   growths,   ulcerating   at   various 
points,  situated  upon  hard,  brawny,  and 
deeply-undermined  skin.     From   the  ul- 
cerative points  pus  excluded,  mixed  with 
characteristic    yellow    granules,    readily 
recognized,  microscopically,  as  actinomy- 
cosis.   Treatment  by  iodide  of  potassium 
and  thyroid  tabloids  appeared  to  be  at- 
tended with  benefit.     (See  colored  plate.) 
J.    J.    Pringle     (Trans,     of    the    Royal 
Medico-Chir.  Soc,  '95). 
2.  Alimentary  Canal. — Teeth. — -The 
fungus  has  been  found  in  cariou  .  teeth 
(Israel),  often  side  by  side  with  leptothrix 
(Senn),  or  almost  pure  cultu      with  no 
manifestation  of  disease  except  chronic 
periodontitis  (Partsch). 

Tongue. — In  man  three  cases  of  this 
affection  have  been  found  on  the  tongue, 
one  of  which  was  of  primary  develop- 
ment; the  other  two  are  believed  to  have 
found  origin  in  a  carious  tooth. 

Case  of  actinomycosis  of  the  pharynx 
in   a   girl   aged    15    years.      The    tonsils 
showed     white     projections     resembling 
masses  of  moss,  which  seemed  to  grow  in 
the    crypts.      The    pharyngeal    wall    also 
showed  these  white  masses.     The  diag- 
nosis   was    established    microscopically. 
G.  Didsbury   (Revue  de  Laryn.,  d'Otol., 
et  de  Rhin.,  Oct.   15,  '95). 
Lingual   actinomycosis   in   cattle   ap- 
pears as  a  nodular  tumor,  with  prolonga- 
tions into  the  parenchyma,  of  ligneous 
hardness. 

Jaius.  —  The  lower  jaw  is  the  most 
frequently  affected.  At  first  the  disease 
resembles  periosteal  sarcoma,  until  the 
loose  tissues  of  the  neck  are  reached, 
when  it  often  rapidly  extends  downward 
along  the  subcutaneoiis  connective  tis- 
sues and  intermuscular  septa.    (Senn.) 

Early  symptom:  Every  patient  who 
without  any  ascertainable  reason  is  un- 
able to  open  the  mouth  is  attacked  by 
actinomycosis  (Poncet).  Patient  who 
had  great  difficulty  in  opening  the 
mouth,  yet  in  whom  the  most  minute  ex- 


-5    -^ 


^ 
3 


CO 

3 


ACTINOMYCOSIS.     SVilPTOMS. 


133 


amination  revealed  no  cause.  Five  or  six 
months  later  an  abscess  formed;  pus 
containing  the  characteristic  yellow 
grains  appeared.  Besnier  (Lyon  M<5d.; 
Eevue  Med.,  Aug.  30,  '99). 

Eight  cases  tending  to  show  that  a  pro- 
portion of  the  cases  ranking  as  alveolar 
abscesses  may  be  due  to  the  specific  or- 
ganism   of    actinomycosis.      Few     cases 
enter  hospital  with  advanced  actinomy- 
cosis of  the  jaw,  and  many  recover  after 
simple  incision  and  after  rupture.     Cer- 
tain cases  of  generalized  disease  in  the 
lungs,  intestinal  tract,  liver,  etc.,  occur 
in  which  the  organism  gained  entrance 
through  the  food,  or  was  swallowed,  and 
therefore    the    surgeon    should    aim    at 
making  external  drainage.    C.  A.  Porter 
(Boston  Med.  and  Surg.  Jour.,  Sept.  13, 
1900). 
The   upper    jaw    is    rarely    primarily 
affected.    It  then  tends  to  attack  rapidly 
the  adjacent  parts,  and  even  the  base  of 
the  skull  and  brain. 

Actinomycosis  may  attack  any  part 
of  the  body,  but  it  is  most  frequently 
located  in  the  cervico-facial  region,  espe- 
cially the  angle  of  the  inferior  maxilla. 
In  this  location  it  may  present  itself  in 
two  forms:  acu-te,  the  symptoms  being 
those  of  a  septic  phlegmon;  subacute, 
in  which  there  is  early  and  continuous 
trismus,  softening,  and  cedema.  Poncet 
(Archives  Prov.  de  Chir.,  Mar.  1,  "96). 

Case  of  intermittent  otorrhoea  suddenly 
attacked  with  fever  and  intense  pain 
behind  the  right  eye,  then  right-sided  tri- 
facial neuralgia,  and  shortly  a  palsy  of 
the  abducens.  The  antrum  A\as  trephined 
and  the  carious  ossicles  removed.  The 
jaws  showed  no  disease.  There  Avas  some 
temporary  improvement,  followed  by  re- 
euning  trouble  in  the  left  ear,  with  a 
drawing  over  of  the  head  like  a  torticol- 
lis. In  an  indurated  swelling  on  the  neck 
actinomycoses  were  found  in  pure  cult- 
ure. Potassium  iodide  was  given.  The 
swelling  rapidly  disappeared,  leaving 
fistulas  behind.  Then  followed  cachexia, 
diarrhoea,  somnolence,  and  death.  The 
autopsy  disclosed  an  actinomycotic  in- 
volvement of  the  base  of  the  brain,  and 
in  the  neck  an  actinomycotic  meningitis. 
Quervain  (Deut.  Zeit.  f.  Chir.,  Apr.,  '99). 


Autopsy  indicating  that  actinomycosis 
of  the  middle  ear  may  arise  from  blood- 
infection  from  a  primary  focus  elsewhere 
in  the  body,  or  from  a  neighboring  ac- 
tinomycotic process  in  the  mouth,  phar- 
ynx, tonsil,  or  from  carious  teeth ;  that 
the  fungus  may  enter  the  middle  ear 
through  the  Eustachian  tube  or  through 
the  external  auditory  canal.  J.  C.  Beek 
(Prager  med.  Woch.,  Mar.  29,  1900). 

In  thi'ce  cases  the  predominant  sign 
was  a  sharply-defined  local  movable  mass, 
which  is  always  strongly  indicative  of 
the  disease.  Hofmeister  (Beit.  z.  klin. 
Chir.,  B.  26,  H.  2,  1900). 

In  the  case  of  a  butcher  the  first  signs 
were  in  the  floor  of  the  mouth  in  the 
form  of  a  pseudoranula :  afterward  swell- 
ing of  the  cheek  showed  characteristic 
yellowish  discharge  and  granules.  Le- 
noir and  Claisse  (Jour,  des  Praticiens, 
July  14,  1900). 

3.  Intestinal  Canal.  —  The  disease 
begins  with  a  sharp  lancinating  pain  in 
the  abdomen  and  follows  the  course  of 
chronic  peritonitis.  Swellings  forming 
abscesses  are  found  on  the  anterior  ab- 
dominal wall  which  sometimes  communi- 
cate with  the  intestine.  It  may  also  start 
from  the  vermiform  appendix.  There 
hare  also  been  cases  of  primarj'  actin- 
omycosis of  the  colon  with  metastatic 
deposits  in  the  liver. 

Case  in  a  man,  21  years  of  age,  who 
passed  through  a  febrile  disease  of  sev- 
eral weeks.  Shortly  afterward  a  swelling 
formed  below  the  crest  of  the  ilium, 
which  disappeared  spontaneously,  but 
eventually  returned.  The  whole  iliac 
fossa  showed  a  hard,  dense  infiltration. 
Free  incision  proved  the  disease  at  once 
to  be  actinomycosis.  At  the  bottom  of 
the  very  large  wound  lay  the  perforated 
appendix.  Later  on  the  ascending  colon 
became  involved.  Ascending  colon  re- 
sected and  the  appendix  extirpated.  F. 
Lange   (Annals  of  Surg.,  Sept.,  '96). 

Case  of  abscess  of  abdominal  walls  in 
which  the  cavity  contained  actinomyco- 
sis and  two  fish-bones.  The  Avhole  mass 
was  excised,  taking  out  the  umbilicus 
and  portions  of  the  rectus  muscle  down 


124 


ACTINOMYCOSIS.     SYMPTOMS. 


to  the  peritoneum,  where  an  intestinal 
adhesion  was  met  with.  Though  hernia 
necessarily  resulted,  no  serious  results 
ensued,  and  the  patient  is  now  quite 
well.  The  actinomycosis  Avas  probably 
a  secondary  infection,  not  present  in  the 
fish-bones  when  eaten,  the  parasite  being 
swallowed  later,  and  having  entered  the 
abscess  from  the  intestine. 

Case  of  actinomycosis  of  the  neck  re- 
moved under  the  impression  that  it  was 
a  tuberculous  abscess.  Mixter  (Boston 
Med.  and  Surg.  Jour.,  July  6,  '99). 

Analysis  of  13  cases  of  ano-rectal  ac- 
tinomycosis obtained  from  literature. 
The  average  age  was  31  years.  Eight 
were  men,  and  9  of  the  patients  lived  in 
the  country.  The  ascending  form  of  in- 
fection is  rarely  secondary,  being  most 
frequently  the  result  of  direct  contact 
with  materials  infected  with  the  ray- 
fungus,  such  as  straw,  hay,  etc.  In  one 
of  the  cases  the  inoculation  was  made  in 
a  perineal  scar  in  a  woman  who  slept 
upon  straw.  In  two  others  inoculation 
arose  from  a  spike  of  wheat  that  the  pa- 
tient had  passed  through  the  urethra. 
Descending  actinomycosis  is  the  most 
common  ano-rectal  form.  It  is  due  to 
the  infection  of  the  wall  of  the  rectum  by 
faecal  matters  that  contain  the  micro- 
organism from  a  previously  diseased 
point  in  the  colon.  Delacroix  (Gaz.  Heb. 
de  Med.  et  de  Chir.,  July,  '99). 

4.  Genito-Ueinart  Tract. — The 
uterus  may  also  become  invaded  by  the 
disease,  the  first  manifestation  being  the 
discharge  of  a  turbid  foetid  fluid  contain- 
ing the  characteristic  shreds  and  masses. 

Case  of  actinomycosis  of  the  uterus  in 
a  woman  64  years  of  age.  For  four  years 
she  had  noticed  a  discharge  from  the 
vulva,  usually  consisting  of  blood,  but 
sometimes  yellowish  and  foetid.  The 
uterus  was  prolapsed.  General  health 
good.  The  uterus  found  slightly  en- 
larged, with  gaping  os.  A  drop  of  the 
foetid  yellow  liquid  was  found  at  the  os. 
Under  the  microscope  these  shreds 
showed  the  characteristic  appearances  of 
actinomycosis.  Vaginal  hysterectomy. 
Recovery.  Davide  Giordano  (La  Clinica 
Chir.,  June,  '95) . 


5.  Bronchial  Tubes  and  Lungs. — 
In  bronchitie  actinomycosis  the  affection 
is  less  severe  in  winter  than  in  summer, 
which  is  the  contrary  of  what  is  observed 
in  ordinary  bronchitis.  It  can  be  classi- 
fied in  three  groups:  (1) lesions  of  chronic 
bronchitis,  (2)  miliary  actinomycosis,  and 
(3)  cases  with  broncho-pneumonia  and 
abscesses.  The  lower  lobe  is  attacked 
more  frequently  than  the  upper;  the  op- 
posite is  the  ease  in  tuberculosis. 

Keview  of  14  recorded  eases  of  actino- 
mycosis of  the  lung.  The  only  2  which 
recovered  were  those  in  which  radical 
operations,  with  resection  of  four  or  five 
ribs,  and  cauterization  of  the  diseased 
cavity  in  the  lung  were  carried  out. 
All  those  that  were  simply  incised  and 
drained  ended  fatally.  The  infection  of 
the  lung  may  be  secondary  to  either 
cervico-facial  or  pharyngeo-oesophageal 
actinomycosis,  or  it  may  be  primary, 
either  through  the  bronchi  or  from  an 
external  wound.  There  are  three  forms 
clinically:  (1)  the  pulmonarj',  with  in- 
sidious onset,  going  on  to  induration  of  a 
large  area  of  lung,  generally  in  the  sub- 
clavicular or  postero-lateral  regions,  the 
apices  being  usually  free;  (2)  the  bron- 
chial, with  a  diffuse  bronchial  catarrh, 
and  foetid  rauco-purulent  expectoration, 
containing  the  fungus;  (3)  the  pleural, 
with  effusion;  the  co-existence  of  pleural 
effusion  with  retraction  of  some  part  of 
the  thoracic  parietes — due  to  fibrous 
changes  in  the  lung — is  pathognomonic. 
Another  pathognomonic  symptom  is  the 
presence  of  a  swelling  in  the  wall  of  the 
thorax  where  it  has  been  invaded  by  the 
fungus,  along  with  shrinking  of  the  lung 
causing  retraction  of  the  thoracic  walls; 
later  on  this  softens  and  becomes  sub- 
fluctuating  without  the  formation  of 
large  abscesses.  Puncture  obtains  a  fluid 
containing  fragments  of  fungus.  Death 
may  occur  after  months  or  years,  ac- 
cording to  the  varying  invasion  of  other 
organs  by  the  disease;  in  one  case  of 
rapid  diffusion  of  the  fungus  death  oc- 
curred in  twenty-four  days.  Parasean- 
dolo  (Brit.  Med.  Jour.,  from  Clinica  Mod., 
Nov.  7,  1900). 


ACTINOMYCOSIS.     DIAGNOSIS.     ETIOLOGY. 


125 


6.  Beain.  —  Here,  tumor-like  symp- 
toms exist  during  life,  with  headache, 
paralysis  of  the  abducens,  congestion  of 
the  optic  papilla,  and  attacks  of  uncon- 
sciousness. 

Necropsy  indicating  the  probable  mode 
of  infection  of  the  orbit  and  brain.  Sinus 
found  leading  from  the  orbit  to  the  gum 
of  the  upper  jaw;  the  ray-fungus  had 
probably  lodged  in  or  near  a  tooth,  as  it 
has  so  often  been  found  to  do.  The 
fungus  Avas  probably  carried  into  the 
system  on  an  ear  of  com  chewed  at  har- 
vest-time. Having  reached  the  orbit,  it 
crept  along  its  outer  wall  and  in  the 
wall  of  the  right  cavernous  sinus  to  the 
base  of  the  brain,  ultimately  setting  up 
meningitis  and  small  abscesses,  and  bur- 
rowing through  the  pituitary  body  and 
sella  Turcica  to  the  cavernous  sinus  of 
the  left  side.  In  all  probability  the  dis- 
ease had  reached  the  cranial  cavity  be- 
fore admission  into  the  hospital.  W.  B. 
Ramson  (Brit.  Med.  Jour.,  June  27,  '96). 
Cerebral  complications  and  death  in  a 
case  of  cervicofacial  actinomycosis  in  a 
man  aged  61.  At  first  localized  in  the 
region  of  the  left  inferior  maxilla,  where 
it  was  mistaken  for  periostitis  from  den- 
tal caries,  it  invaded  later  the  upper  part 
of  the  neck  and  the  temporal  region. 
Here  it  caused  a  subperiosteal  abscess, 
which,  spreading  to  the  spheno-maxillary 
fossa  and  the  back  of  the  orbit,  finally 
infected  the  meninges  through  the 
sphenoidal  fissure.  A  seeondai-y  infec- 
tion by  a  slender  bacillus  produced  an 
abscess  in  the  left  temporal  lobe  contain- 
ing foetid  pus.  This  abscess  burst  into 
the  lateral  ventricle,  which  was  consider- 
ably dilated,  and  produced  coma  and 
death  about  seven  months  and  a  half 
after  the  appearance  of  the  first  symp- 
toms. Bourquin  and  de  Quervain  (Rev. 
Med.  de  la  Suisse  Rom.,  Mar.  20,  '97). 

Diagnosis. — When  the  process  is  very 
rapid,  actinomycosis  may  stimulate  acute 
phlegmonous  inflammation  and  osteo- 
myelitis;  or,  when  wide-spread,  syphilis. 

Sarcoma.  —  This  form  of  neoplasm 
does  not  suppurate  or  break  down  so 
early. 


In  the  jaws  it  is  to  be  differentiated 
from  dental  affections:    epulis. 

Tuberculosis.  —  In  this  disease  the 
lymphatic  glands  are  infected,  and  the 
apices  are  usually  the  first  involved. 

CARCiNOiiA.  —  The  skin  or  mucous 
membrane  involved  is  in  close  connection 
with  the  tumor;  in  actinomycosis  the 
skin  will  be  found  broken  on  microscop- 
ical examination. 

Syphilis. — A  gumma  will,  in  two  or 
three  weeks,  be  sensibly  affected  by  large 
doses  of  potassium  iodide,  which  does  not 
act  so  rapidly  in  actinomycosis. 

The  undoubted  influence  exercised  by 
iodide  of  potassium  countenances  the 
suspicion  that  many  patients  supposed 
to  be  syphilitic  have  really  been  actino- 
mycotic. Poncet  (Glasgow  Med.  Jour- 
nal, Apr.,  '95). 

Lupus.  —  The  diagnosis  depends,  in 
this  condition,  upon  microscopical  ex- 
amination. 

Etiology. — Both  men  and  animals  are 
probably  infected  from  vegetables  or 
water  (Israel),  from  eating  ears  of  bar- 
ley, or  rye,  when  the  fungus  penetrates 
through  the  wound  or  abrasion  thus  pro- 
voked, or  in  many  cases  through  carious 
teeth.  Intestinal  actinomycosis  is  due  to 
taking  contaminated  food  or  water,  when 
the  fungus  becomes  implanted  upon  an 
already  diseased  tissue,  multiplies,  and 
causes  active  proliferation  of  the  submu- 
cous tissue. 

Case  where  the  affection  was  trans- 
mitted by  kissing,  between  bridegroom 
and  bride.  Baracz  (Wiener  med.  Presse, 
Jan.  6,  '89). 

[Farmers  should  be  warned  against 
the  habit,  so  common  among  them,  of 
chewing  bits  of  straw,  wheat,  oat-chafi, 
etc.,  the  most  prolific  cause  of  the  dis- 
ease.   E.  Laplace.] 

Actinomycosis  is  frequently  met  with 

in  shoe-makers.     This  is  due  to  their  habit 

of  placing  their  needles  in  their  mouths. 

Ullmann    (Le  Bull.  Med.,  Nov.   17,  "97). 

Actinomycosis   of   the   lower   jaw    ac- 


126 


ACTINOMYCOSIS.    PATHOLOGY. 


quired  by  a  tootli-brush  maker  in  the 
following  manner:  Hogs'  bristles  -nere 
washed,  then  held  in  mouth  before  stick- 
ing into  the  handle-holes  in  bundles. 
Guinard  (Bull,  et  Mem.  de  la  Soc.  de 
Chir.  de  Paris,  T.  26,  No.  6,  1900). 

Total    of    72    cases    of    actinomycosis 
from   American   sources   collected.      Six 
personal  cases,  2  of  which  had  not  been 
previously  reported.    In  one  alveolar  ab- 
scess    followed     chewing     wheat-grains 
with  a  carious  tooth.    In  a  second  case 
a  quantity  of  pus  collected  in  the  right 
iliac  fossa.     The  patient  died  of  malnu- 
trition,  having   recurred    after    evacua- 
tion.   J.  Rfihrah  (Annals  of  Surg.,  Feb., 
1900). 
Pathology.  —  The  actinomycoses  were 
formerly     thought    to    be    mold-fungi 
(hyphomycetes),  but  Bostroem,  in  1885, 
proved  by  cultivating  them  that  they 
were  a  -variety  of  cladothrix,  belonging 
to  theschizomycetes. 

The  mass  is  made  up  of  granulation 
tissue,  which,  except  for  the  presence  of 
the  ray-fungus,  would  be  mistaken  for 
a  round-celled  sarcoma.  Epithelioid  ele- 
ments and  giant  cells  are  also  seen.  In 
the  granular  mass,  or  in  the  pus  coming 
from  a  case  of  actinomycosis,  the  fiingus 
itself  appears  under  the  form  of  small, 
yellow,  brown,  or  even  green  masses, 
about  a  pin-head  in  siz€,  which,  on 
microscopical  examination,  are  found  to 
be  composed  of  a  central  interwoven 
mass  of  threads,  from  which  radiate 
club-shape-ended  rays;  in  some  speci- 
mens certain  rays  project  far  beyond  the 
others.  In  man  the  clubbed  bodies  are 
frequently  absent  (Senn).  The  histo- 
logical lesions  are  alike  in  the  actino- 
mycotic nodule  and  in  the  tuberculous 
follicle;  only  the  foreign  body  differs. 
"Water  or  a  weak  solution  of  sodium 
chloride  causes  the  rays  to  swell  enor- 
mously and  lose  their  shape;  ether  and 
chloroform  have  no  action  upon  them. 

The  yellow  grains  are  not  always  to 
be  found  in  fistulse,  etc.,  unless  they  are 


carefully  sought  in  scrapings,  etc.  An 
early  diagnosis  is  essential,  since  later 
the  disease  may  be  beyond  the  resources 
of  therapy.  A.  Poncet  and  L.  Berard 
(Le  Bull.  Med.,  Mar.  28,  1900). 

Case  in  which  microscopically  there 
was  no  appearance  of  the  ray-fungus 
in  the  fresh  pus,  and  yet  microscopical 
examination  showed  the  presence  of  fun- 
gus at  once.  The  absence  of  the  typical 
grouping  of  the  micro-organisms  is  not 
sufficient  to  exclude  the  diagnosis  of 
actinomycosis,  as  the  micro-organisms 
tend  to  arrange  themselves  in  different 
waj's  at  different  times.  W.  Silber- 
schmidt  (Deutsche  med.  Woch.,  Nov. 
21,  1901). 
At  a  certain  stage  there  are  in  every 
colony  three  elements, — viz.: — 

1.  Club-shaped  formations. 

2.  A  centrally-placed  net-work  of  fun- 
goits  filaments  of  varying  shape  and  size. 

3.  Fine  coccus-like  bodies  (spores), 
which  originate  from  the  fungous  fila- 
ments, and  grow  into  long  rods  and 
branching  twigs. 

Typical  actinomycosis  is  the  disease  in 
which  occur  the  characteristic  mycelial 
masses,  having  club-shaped  radiations. 
Atypical  actinomycosis  includes  such 
diseases  as  Nocard's  farcin  de  hmuf,  and 
infections  which  clinically  and  anatomic- 
ally resemble  actinomycosis,  and  are 
caused  by  branching  mycelial  organisms 
which  correspond  quite  closely  to  the 
cultural  peculiarities  of  the  streptothrix 
actinomj'ces,  but  fail  to  form  the  char- 
acteristic grains  in  the  tissues  and  pus. 
Berestneff  (Zeit.  f.  Hyg.  u.  Infekt.,  vol, 
xxix,  p.  94,  '98). 

Staining. — The  following  stains  have 
been  used: — 

Wedl's  orseille  (Weigert). 

Eosin  (Marchand). 

Cochineal — red  (Dunker  and  Mag- 
nussen). 

Hffimatoxylin  alum  (Moosbrugger). 

Gram's  method  —  section  staining 
(Partsch). 

Safranin  in  aniline  oil,  followed  by 
K.  I.  (Babes). 


ACTINOMYCOSIS.    PATHOLOGY. 


127 


Solution  of  orcein  in  acetic  acid 
(Israel). 

Picrocarmin — fungus,  yellow;  other 
parts,  red  (Baranski). 

The  actinomyces  in  a  section  are  best 
shown  by  Gram's  method,  first  with 
methyl-violet,  then  with  Bismarck  brown 
(Tillmann). 

Cultivation. — It  is  difficult  to  culti- 
vate in  coagulated  blood-serum  (0. 
Israel),  coagulated  blood-serum  and 
agar-agar  (Bostrom),  and  coagulated 
egg-albumin  and  agar-agar  ("Wolff  and 
J.  Israel). 

From  5  typical  cases  of  human  ac- 
tinomycosis numerous  inoculations  were 
made  upon  various  media,  which  were 
kept  partly  under  aerobic,  partly  under 
anaerobic,  conditions;  growth  of  strepto- 
thrix  actinomyces  took  place  in  only  20 
of  64  primary  cultures.  After  the  first 
generation  the  organism  did  better  when 
grown  without  oxygen;  the  actinomj'ces 
grew  well  when  inoculated  in  eggs  in  the 
usual  manner.  The  colonies  consisted 
of  longer  and  shorter  threads,  which 
stained  by  Gram's  method,  and  always 
presented  true  branching,  although 
sometimes  the  branches  were  hard  to 
find;  the  cultures  were  rather  short- 
lived; in  one  case  the  growths  lived 
through  11  generations  during  7  months; 
in  two  cases  through  4  generations  in 
3  ^/s  months,  but  in  five  cases  death  oc- 
curred after  the  first  generation.  In 
inoculation  experiments  on  rabbits, 
guinea-pigs,  and  mice  a  fatal  actinomy- 
cosis was  not  produced,  although  many 
features  recalled  the  pictures  of  the 
disease.  Francis  Harbitz  (Norsk  Mag. 
f.  Laegevidensk.,  vol.  lix,  p.  1,  '98). 

Inoculation. — It  has  been  successfully 
carried  out  by  James  Israel  and  Ponfick, 
from  tissue  and  from  pure  cultures. 

In  one  inoculation  experiment  a  char- 
acteristic deep-yellow  tumor  was  found 
in  the  liver,  proving  a  general  infection. 
In  all  other  inoculation  experiments  the 
author  had  found  the  tumor  remaining 
limited  to  the  peritoneal  cavity  and  con- 
sequently improbable  of  causing  general 


infection.      Ma.x    Wolfl'    (Deutsche    med. 
Woch.,  Mar.  1,  8,  '94). 

Opinions  differ  as  to  its  power  of  pro- 
ducing pus,  a  secondary  infection  by  the 
pus-germs  being  thought  the  true  cause 
of  the  pus  sometimes  found  with  actin- 
omycosis. Dissemination  by  ■  the  lym- 
phatic system  never  occurs.  Glandular 
enlargement  indicates  secondary  infec- 
tion. 

In  pure  infection  with  the  actinomyces 
fungus  the  pus  secreted  is  not  always 
tliin.  This  fungus  alone,  without  the 
admixture  of  the  ordinary  pus-produeing 


(I,  Ray-fungus  or  masses,  showing  central 
mycelium  of  actinomycosis.  6,  White 
blood-corpuscles,  showing  their  rela- 
tive size.     (Poncet  and  Berard.) 

micro-organisms,   can   produce   suppura- 
tion.   The  entrance  of  the  common  pus- 
producing  micro-organisms  into  actino- 
mycotic  foci   does  not   kill  the   fungus ; 
but,  on  the  contrary,  may  bring  about 
such    conditions    as    favor   its    develop- 
ment.     Kozerski    (Archiv   f.   Derm.    u. 
.'^iyphilis,  B.  38,  H.  2,  '96). 
1.    Cutaneous     Sueface.  —  Around 
the  primary  lesion  are  small  secondary 
lesions.     Two  forms  are  described:    (a) 
The  anthracoid,  which  pursues  a  rapid 
course,  with  fever,  and  sometimes  septi- 
casmic  in  character.     It  is  characterized 


128 


ACTINOMYCOSIS.    PATHOLOGY. 


by  flat  tumefaction,  with  multitudes  of 
small  openings  with  yellow  granulations, 
from  which  thick  pus  exudes.  (&)  The 
ulcero-fungous,  which  pursues  a  sub- 
acute course,  with  tendency  to  ehronic- 
ity.  In  the  face  it  tends  to  form  bur- 
rowing abscesses  instead  of  recognizable 
tumors. 

2.  Bronchial  Tttbes  and  Lungs. — 
Some  observers  believe  that  the  peri- 
bronchial lymphatic  vessels  and  glands 
disseminate  the  fungus  or  its  spores  in 


bronchitis  and  pain  in  the  left  side,  but 
from  this  recovery  had  apparently  taken 
place.  Six  ounces  of  curdy  pus  evacu- 
ated, revealing  actinomycosis.  The  tem- 
perature remained  high.  Three  swell- 
ings successively  opened.  As  sinuses 
persisted,  the  patient  was  put  in  a  hath 
of  weak  iodine  and  under  iodide  of 
potassium  marked  improvement,  when 
death  occurred  under  chloroform  admin- 
istered for  the  extraction  of  a  tooth. 
Left  lung  found  quite  collapsed,  hut 
otherwise  normal,  and  incased  in  a 
brawny    material    containing    abscesses. 


«-0     o      0 


Eay- fungus  (c,  c,  c),  club-shaped  bodies  (d,  d,  d);  and  spores  (a,  a,  a)  found  in  the 
pus  of  actinomycosis.     (Poneet  and  Birard.) 


the  lungs;  when  the  fungus  reaches  the 
lung-tissue  proper,  granulation  tissue  is 
formed,  which,  through  secondary  in- 
fection, suppurates.  Amyloid  degenera- 
iion  of  other  organs  may  occur,  or 
metastasis  of  the  disease,  in  case  a  pul- 
monary vein  has  been  pierced.  At  times 
the  pericardium  or  peritoneum  becomes 
affected.     (Striimpell.) 

Case  of  actinomycosis  of  pleura  and 
chest-wall  in  a  child,  aged  6,  admitted 
into  St.  Bartholomew's,  suffering  from 
empyema   of  the   left  side.     History   of 


Prolonged  search  needed  to  discover 
actinomycosis.  F.  S.  Eve  (Brit.  Med. 
Jour.,  Apr.  10,  '97). 

3.  Alimentary  Canal. — In  the  jaws 
the  mass  usually  resembles  a  sarcoma, 
but,  if  incised  before  secondary  infec- 
tion and  suppuration  has  occurred,  the 
reddish  surface  will  be  seen  to  be  inter- 
mingled with  yellowish  spots,  which  are 
collections  of  actinomyces. 

In  the  intestines  the  fungus  causes 
proliferation  of  the   submucous  tissue. 


ACTINOMYCOSIS.    PROGNOSIS.    TREATMENT. 


129 


and  whitish  patches  in  the  intestines. 
External  fistulfe  are  commonly  found. 

Actinomycotic  growths  in  the  liver 
in  man  have  a  characteristic  naked-eye 
appearance,  from  their  peculiar  honey- 
combed structure.  The  cases  between 
the  fibrous  trabeculse  are  full  of  caseous 
matter  in  which  the  more  or  less  sphe- 
roidal masses  of  the  fungus  are  im- 
bedded. In  museum  specimens,  which 
have  been  for  some  time  preserved  in 
spirit,  the  contents  of  the  loculi  may 
have  fallen  out^  and  the  honey-combed 
appearance  is  then  much  more  marked 
than  in  recent  specimens.  Crookshank 
(Lancet,  Jan.  2,  '97). 

Condition  of  metabolism  in  patient  sub- 
ject of  toxic  influence  of  actinomycosis. 
Of  abnormal  elements  in  the  urine,  al- 
bumin and  peptone  (?)  were  found  in 
traces,  while  urobilin  was  present  in  ex- 
tremely slight  amount.  Acetone  and 
sugar  absent;  nitrogen-excretion  largely 
exceeded  ingestion ;  reaction  of  urine  was 
not  distinctly  changed;  urea  was  slightly 
decreased.  AUoxur  bodies  varied  propor- 
tionally to  variation  in  excretion  of  nitro- 
gen. Uric  acid  bore  no  definite  relation 
to  amount  of  xanthin  bases.  Ammonia 
was  not  increased,  while  total  sulphates 
bore  direct  relation  to  amount  of  nitro- 
gen, but  ethereal  sulphates  are  not  in- 
creased. Excretion  of  phosphates  not 
changed,  except  slight  decrease  in 
amount  of  earthy  phosphates  and  chlo- 
rides. R.  Schmidt  (Centralb.  f.  innere 
Med.,  Feb,  26,  '98). 

Prognosis.  —  The  prognosis  is  serious 
in  proportion  to  the  rapidity  with  which 
suppuration  occurs.  Actinomycosis  of 
the  upper  jaw  is  more  serious  than  actin- 
omycosis of  the  lower  jaw,  as  it  has  a 
greater  tendency  to  invade  the  deep 
structures.  Internal  actinomycosis  is 
almost  always  fatal,  owing  to  its  inacces- 
sibility. External  actinomycosis  may 
cause  death  from  pyaemia,  septicaemia, 
and  exhaustion.  When  so  placed  as  to 
be  easily  removed  and  treated  early  the 
prognosis  is  favorable.  A  permanent 
recovery  usually  follows  a  complete  re- 


moval of  the  primary  focus,  as  metas- 
tasis is  rare.    (Senn.) 

Actinomycosis  has  a  pronounced  tend- 
ency to  spontaneous  recovery  except  in 
internal  organs.     (Schlange.) 

From  an  analysis  of  sixty  cases  the  fol- 
lowing conclusions  are  reached:  When 
the  disease  involves  the  head  and  neck, 
except  in  a  few  cases  when  the  base  of 
the  skull  is  invaded,  the  course  is  favor- 
able, recovery  taking  place  in  from  three 
to  nine  months.  It  is  exceptional  for 
the  fistula  to  persist  or  to  form  anew, 
after  the  lapse  of  a  year.  Pulmonary 
actinomycosis  may  terminate  in  recovery. 
The  prognosis  of  actinomycosis  is  the 
more  favorable  as  the  anterior  abdominal 
walls  are  involved  and  the  posterior 
escape.  Death  usually  results  from  amy- 
loid degeneration  and  wasting.  If  actin- 
omycosis present  pyEemie  manifestations, 
a  fatal  termination  is  to  be  expected,  as 
a  number  of  vital  organs  are  likely  to  be 
involved.  Actinomycosis  may  pursue  a 
chronic  course,  continuing  thirteen  years 
or  longer,  if  functionally  important  or- 
gans be  not  involved,  as  when  the  process 
confines  itself  to  the  connective  tissue 
about  the  spinal  column. 

Treatment. 

1.  General. — Potassium  iodide  was 
found  useful  in  animals  by  Thomassen 
and  Nocard.  In  man  it  should  be  thor- 
oughly tried  before  surgical  intervention 
is  resorted  to,  especially  when  the  dis- 
ease is  so  extensive  as  to  prevent  com- 
plete removal  by  surgery.  The  results 
obtained  from  iodide  of  potassium  have 
been  remarkable  in  some  eases  and  nega- 
tive in  others.  This  divergence  of  views, 
according  to  Fernet,  depends  on  the 
variation  in  the  virulence  of  the  disease, 
in  its  evolution  in  different  individuals, 
in  the  difference  existing  in  the  receptiv- 
ity of  the  tissues,  and  on  the  influence  of 
secondary  infective  processes.    In  recent 


130 


ACTIKOMYCOSIS.    TKEATMENT. 


and  purely  actinomycotic  lesions  the  re- 
sults may  be  excellent;  in  old-standing 
cases,  and  wliere  the  ray-fungus  is  asso- 
ciated with  streptococci,  staphylococci, 
and  the  bacterium  coli  commune,  the 
drug  treatment  is  less  successful. 

Two  easeSj  one  of  severe  jaw  actino- 
mycosis and  one  of  actinomycotic  peri- 
typhlitis, cured  by  the  use  of  iodide  of 
potassium.  Experiments  showing  that 
the  remedy  does  not  destroy  the  actino- 
mycosis, but  hinders  its  development  and 
reproduction.  Josef  Jurinka  (Mitthei- 
lungen  aus  den  Grenzgebieten  d.  Med.  u. 
Chir.,  vol.  i,  H.  2,  '96) . 

In  two-thirds  of  the  cases  of  chronic 
actinomycosis  of  the  face  and  neck  the 
results  of  iodide  treatment  are  nil.  In 
three-fourths  of  the  recent  cases  recovery 
has  been  obtained  by  it,  combined  with 
surgical  treatment,  and  in  one-fourth  by 
iodide  treatment  alone.  Potassium  iodide 
cannot  be  regarded  as  specific  in  actino- 
mycosis in  man.  If,  at  the  end  of  some 
weeks,  improvement  is  slight  only,  oper- 
ative interference  should  be  carried  out 
at  once.    Berard  (France  Med.,  '97). 

Iodide  of  potassium  does  not  act  on 
the  parasite  itself,  as  cultivations  of  the 
fungus  in  the  usual  media  are  not  influ- 
enced by  it  in  any  way.  The  drug,  to 
be  efficacious,  must  be  given  in  doses  of 
from  15  to  90  grains  a  day  for  some 
weeks.  Some  observers  record  immedi- 
ate and  lasting  effects  from  its  use; 
others  regard  the  surgical  treatment  of 
primary  importance.  George  Pemet 
(Brit.  Jour,   of  Derm.,  Oct.,  '97). 

Drugs  most  successful  in  pulmonary 
actinomycosis  are  potassium  iodide  and 
eucalyptus.  If  there  is  any  involvement 
of  chest-wall,  surgical  treatment  should 
be  undertaken.  Sabrazes  and  Cabannes 
(Revue  de  Med.,  Jan.  10,  '99). 

Four  caseSj  in  one  of  which  the  tumor 
was  situated  below  the  angle  of  the 
scapula.  All  the  patients  were  given 
iodide  of  potassium,  and  the  wounds  were 
treated  with  peroxide,  tincture  of  iodine 
in  full  strength  or  solution,  and  packed 
in  iodoform  gauze  until  all  evidence  of 
presence  of  the  fungus  had  disappeared. 


J.    C.   Munro    (Boston   Med.   and   Surg. 
Jour.,  Sept.  13,  1900). 

The  injection  of  a  5-per-cent.  solution 
of  permanganate  of  potassium  into  the 
cysts  has  been  of  advantage. 

Case  in  which  a  swelling  over  the 
twelfth  rib  near  the  spine  caused  severe 
pain.  The  hypodermic  injection  into  the 
mass  of  15  minims  of  a  5-per-cent.  solu- 
tion of  permanganate  of  potash  followed 
by  marked  relief.  Iodide  of  potassium, 
45  increased  to  90  grains  daily,  had  no 
control  over  the  progress  of  the  disease. 
H.  B.  Mclntire  (Boston  Med.  and  Surg. 
Jour.,  Jan.  28,  '97). 

2.  SuHGiCAL. — Local  measures  which 
do  not  completely  remove  the  infected 
tissues  do  harm,  as  they  frequently  give 
rise  to  secondary  infection,  rapid  exten- 
sion, and  death. 

Cauterization  with  solid  silver  nitrate 
in  actinomycosis  of  skin  and  soft  parts 
in  which  suppuration  and  fistulous  tracts 
have  occurred  possesses  a  specific  action 
on  the  actinomycosis  (Kottnitz). 

Case  in  which  local  applications  and 
injections  of  nitrate  of  silver  and  nitrate 
of  zinc,  both  into  the  sinuses  and  directly 
into  the  tissues,  caused  some  argyriasis, 
but  recovery.  A.  Mayer  (Annals  of 
Surg.,  Sept.,  '96). 

Case  of  pulmonary  actinomycosis  which 
at  first  had  been  mistaken  for  gangrene. 
For  fcetid  breath  and  expectorations,  oil 
of  eucalyptus  was  prescribed,  in  doses  of 
5  grains  at  first;  later  10  grains  in  gela- 
tin capsules,  every  four  hours  day  and 
night.  Three  inhalations  daily  were 
ordered  of  the  remedy.  Under  this  treat- 
ment a  cure  was  rapidly  attained.  G. 
Butler  (Nouv.  Eem.,  xlv,  p.  288,  '98). 

3.  Electeotechnical.  —  Two  plati- 
num needles,  attached  to  the  two  poles 
of  a  constant-current  battery,  are  to  be 
inserted  into  the  tumor.  Through  the 
two  needles  a  current  of  50  milliamperes 
is  to  be  passed,  while  every  minute  some 
drops  of  a  10-per-cent.  iodide-of-potas- 
sium  solution  are  to  be  injected  into  the 
mass.     The  solution  is  decomposed  into> 


ACTINOMYCOSIS. 


ACTOL. 


131 


nascent  iodine  and  potassium.  This  is 
repeated  every  eight  days,  each  session 
lasting  twenty  minutes,  under  an  anaes- 
thetic.   (Gautier.) 

Before  suppuration  all  diseased  tissues, 
glands,  etc.,  should  be  removed  and  the 
parts,  when  possible,  cauterized  with  the 
thermocautery. 

After  suppuration  the  parts  should  be 
treated  as  if  they  were  tuberculous, 
curetting  and  packing  with  iodoform 
gauze  (Senn). 

Case  of  aetinom3'cosis  of  the  lower 
portion  of  the  abdomen,  communicating 
with  the  bladder,  in  which,  when  all  had 
failed,  a  cure  was  effected  after  the  use 
of  fifteen  tuberculin  injections,  com- 
mencing with  Vo  minim  and  ending  with 
4  minims.  After  the  usual  disturbance, 
local  and  general,  the  growth  disap- 
peared entirely.  Billroth  (Wiener  med. 
Woch.,  Mar.  7,  '91). 

The  disease  was  first  noted  in  America 
in  1888.  Up  to  the  present  time  100 
cases  have  been  observed  in  America. 
Of  the  5  cases  observed  in  the  hospital, 
the  disease  was  primary  in  the  cervico- 
facial region  in  1,  in  the  thoracic  region 
in  1,  and  in  the  remaining  3  cases  in 
the  abdominal  region.  One  of  the  ab- 
dominal eases  died  and  1  recovered. 
The  sixth  case,  the  disease  being  ab- 
dominal, terminated  fatally.  It  is  a 
curious  fact  that  less  than  20  of  the 
100  cases  came  from  the  Southern 
States,  and  only  2  of  them  were  in 
negroes.  Seventy-two  of  the  whole 
number  were  men  and  only  23  women. 
The  youngest  case  was  a  child  of  6, 
the  oldest  a  man  of  70.  In  36  of  the 
eases  the  patients  were  more  or  less 
connected  with  farming  and  with  the 
handling  of  grain.  In  most  cases  there 
was  no  definite  history  of  infection,  but 
in  several  the  habit  of  biting  straw  and 
carrying  it  in  the  mouth  had  been  in- 
dulged in.  In  18  of  the  eervieo-facial 
eases  it  was  found  that  a  carious  tooth 
was  the  point  of  entrance  of  the  para- 
site. The  author  emphasizes  the  point 
that  no  diagnosis  should  be  made  unless 
the  ray-fungus  is  found.  It  appears 
that    in    .53    of    the    cases    the    malady 


affected  the  eervieo-facial  region,  in  20 
the  thoracic  region,  and  in  23  the  ab- 
domen. Only  in  4  cases  was  the  disease 
primary  in  the  skin,  but  there  is  a 
tendency  for  the  malady  to  spread,  and 
for  metastases  to  occur.  Recovery  oc- 
curred in  45  cases,  and  improvement  in 
14.  In  32  death  resulted,  and  in  9  no 
improvement  was  noticed.  Surgical 
treatment  is  indicated,  but  repeated 
operations  may  be  necessary.  Simple 
incision  and  drainage  do  not  cure  the 
disease,  which  is  almost  certain  to  recur 
if  the  treatment  be  limited  to  such  pro- 
ceedings. Iodide  of  potassium  seems  to 
be  of  very  doubtful  efficacy.  It  has  no 
action  upon  the  ray-fungus,  and,  as  it 
is  said  to  act  effectively  only  when  used 
in  conjunction  with  surgical  operation, 
it  follows  that  its  influence  is  more  than 
doubtful  in  most  cases.  W.  G.  Erving 
(Treatment;  from  Bull.  Johns  Hopkins 
Hosp.,  Nov.,  1902). 

Eenest  Laplace, 

Philadelphia. 

ACTOL.  —  Actol,  or  lactate  of  silver, 
is  a  bactericidal  agent  recommended  by 
Crede  and  Baj'er  as  a  powerful  disin- 
fectant for  wounds.  It  forms  a  soluble 
compound  with  the  secretions,  and  this, 
being  absorbed,  influences  beneficially 
not  only  the  lesion  treated,  but  also  the 
neighboring  tissues.  It  is  non-poison- 
ous: a  point  of  great  superiority  over 
other  equally  active  antiseptics. 

Dose.  —  Subcutaneously,  the  drug  is 
injected  in  '^/^-gia.m  doses,  dissolved  in  1 
drachm  of  water.  This  may  be  repeated 
frequently.  Locally,  actol  is  used  in  the 
proportion  of  1  to  4000;  stronger  solu- 
tions tend  to  color  the  skin  of  the  hands. 

Physiological  Action.  —  Guinea-pigs 
were  injected  with  0.03  to  0.04  per  cent, 
of  their  body-weight  of  lactate  of  silver, 
and  received  subsequently,  after  an  in- 
terval varying  from  ten  minutes  to  three 
hours,  half  a  drop  of  a  violent  cholera 
culture.  In  every  case  the  animals  suc- 
cumbed as  rapidly  as  those  used  in  eon- 


132 


ACTOL. 


ADDISON'S  DISEASE. 


trolling  the  results.  Similar  experiments 
with  other  animals  and  virulent  diseases 
have  given  the  same  results,  showing 
that  actol  possesses  no  value  as  a  general 
disinfectant. 

A  series  of  experiments  performed  by 
Marx,  however,  have  shown  actol  to  be  a 
powerful  local  disinfectant.  Two  series 
of  researches  with  anthrax  bacilli  showed 
that,  in  the  first  place,  it  protected  the 
seat  of  injection  completely  against  the 
swarms  of  micro-organisms  in  the  blood 
and  that  it  had  an  actual  local  bacteri- 
cidal action  in  respect  to  these  bacilli. 

In  spite  of  its  failure  to  produce  an 
antitoxic  serum,  actol  is  one  of  the  most 
powerful    and    at   the    same   time    most 
harmless  bactericidal   agents  at  present 
1  before  the  profession.     Marx    (Centralb. 

f.  Bakteriol.,  Nos.  15  and  16,  '97). 
Therapeutics. — Actol  may  be  injected 
under  the  skin  in  surgical  affections. 
Crede  has  thus  administered  15  grains  in 
solution  without  witnessing  the  least  un- 
toward effect.  Two  grains  to  the  ounce 
of  water  must  not  be  surpassed  in 
strength,  however,  lest  the  solution  cause 
coagulation  of  the  albumin  of  the  sub- 
cutaneous tissue  and  arrest  the  dissemi- 
nation of  the  remedy.  In  anthrax,  fu- 
runcle, and  erysipelas  it  is  said  to  be 
effective  when  used  in  the  above  manner. 
It  may  also  be  used  in  1  to  4000  solu- 
tions as  a  mouth-wash,  gargle,  etc.,  in 
inflammatory  and  infectious  disorders, 
owing  to  the  favorable  influence  of  silver 
salts  upon  mucous  membranes  in  general. 

ACUTE  RHINITIS.  See  Nasal  Cavi- 
ties. 

ACUTE   YELLOW   ATROPHY.      See 

LiVEK. 

ADDISON'S  DISEASE. 
Definition.  —  A  disease  characterized 
by  progressive  asthenia,  blood-impover- 


ishment, frequent  disorder  of  the  gastric 
and  intestinal  functions,  cardiac  weak- 
ness, and  irregular  pigmentation  of  the 
surface  in  the  form  of  bronze-colored 
spots,  and,  when  not  interfered  with, 
uniformly  tending  toward  a  fatal  result. 
It  was  first  investigated  and  described 
as  a  distinct  form  of  disease  under  the 
name  of  "Bronzed  Skin  Disease"  by  Dr. 
Thomas  Addison,  of  London,  in  1855. 
Since  that  time  it  has  very  generally 
been  called  "Addison's  disease,"  and  as- 
sociated with  disease  of  the  suprarenal 
capsiiles. 

Symptoms.  —  Perhaps  the  earliest 
symptoms  to  attract  attention  in  this 
disease  are  those  of  asthenia,  or  lack  of 
energy  and  endurance,  with  a  variable 
condition  of  the  digestive  organs,  and 
slight  anffimic  appearance  of  the  surface. 
As  the  disease  progresses  the  asthenia  is 
manifested  by  shortness  of  breath,  hur- 
ried and  irregular  action  of  the  heart, 
and  great  sense  of  weariness  from  very 
moderate  exercise.  Sometimes  there  are 
present  vertigo,  tinnitus  aurium,  and 
syncope.  The  appetite  is  variable,  but 
generally  impaired,  with  occasional  at- 
tacks of  pain  in  the  epigastrium  and  left 
side  of  the  chest,  increased  by  attempts 
to  exercise.  Moderate  constipation  exists 
in  most  cases,  but  is  interrupted  by  in- 
creasingly frequent  attacks  of  diarrhoea, 
and  sometimes  vomiting. 

The  foregoing  symptoms  are  so  much 
like  those  of  pernicious  anemia  that 
Addison's  disease  might  not  be  suspected 
until  the  characteristic  pigmentation  be- 
comes noticeable  on  some  part  of  the 
surface.  In  most  cases  the  pigmented, 
or  dark-brown,  spots  appear  first  on  the 
face  and  backs  of  the  hands,  varying 
much  in  size  and  in  color.  The  latter  is 
generally  at  first  a  light-brown  or  olive 
hue,  but  grows  darker  and  the  spots 
larger  as  the  disease  progresses.     Spots 


Bronzmq  of  the  Skin  in  Addison's  Disease.  (Byrom  Bramwell  I 


^S     OF    CLINICAL     MEOP 


Appearance  of  the  tongue  and  nipple  m  Addison's  Disease. (ByromBramweil 


LAS     OF    CLINICAL     MEDICINE, 


ADDISON'S  DISEASE.    SYMPTOMS. 


133 


also  appear  around  the  nipple,  in  the 
axilla,  on  the  genital  organs,  and  where- 
ever  the  surface  is  exposed  to  much  fric- 
tion from  the  clothing,  and  in  some  cases 
they  spread  until  they  occupy  nearly  the 
whole  cutaneous  surface,  imparting  to 
the  patient  much  the  same  color  as  the 
mulatto  or  half-bred  negro.  {See  colored 
Plate  I.) 

The  palms  of  the  hands  and  soles  of 
the  feet  generally  remain  white.  Brown 
or  pigmented  spots  in  many  eases  appear 
on  the  tongue  and  other  parts  of  the 
mouth  and  in  the  vagina.  Spots  have 
been  described  on  the  serous  membranes 
in  a  very  few  cases.  (See  colored  Plate 
11.) 

In  a  majority  of  cases  the  patients 
have  complained  of  asthenia  for  a  con- 
siderable time  prior  to  the  appearance 
of  noticeable  pigmentation  on  the  sur- 
face. In  a  few  instances  the  bronzed 
spots  have  been  the  first  symptoms  to 
attract  attention.  Cases  in  which  bronz- 
ing does  not  accompany  the  other  sj'mp- 
toms  are  not  infrequent. 

Case  of  subacute  suprarenal  cachexia 
without  pigmentation.  The  patient  had 
shown  only  two  symptoms:  (1)  an  un- 
interrupted rise  of  temperature  during  a 
month  and  a  half,  and  (2)  a  progressive 
cachexia  marked  by  loss  of  flesh  and  in- 
ability to  undergo  any  muscular  strain. 
Death  followed  about  two  months  after 
the  beginning  of  the  affection.  On  post- 
mortem examination  only  the  adrenals 
were  found  diseased;  they  showed  a 
caseous  suppurative  degeneration  of 
tubercular  origin.  The  mucous  mem- 
branes did  not  show  the  smallest  sign 
of  pigmentation.  E.  Marie  (La  Presse 
Medicale,  July  24,  '95). 

Cases  in  which  there  existed  patholog- 
ical changes  in  the  adrenals  without  the 
existence  of  pigmentary  deposits  in  the 
skin  or  mucous  membranes:  Lejars 
(Bull,  de  la  Soc.  Anat.,  Mar.) ;  Perry 
(Brit.  Med.  Jour.,  June  7)  ;  Pilliet  (Bull. 
de  la  Soc.  Anat.,  Xo.  2G) ;  Bradshaw 
(Liverpool    Medico-Chirurgical    Journal, 


July);  Davidson  (Liverpool  Medico-Chi. 
Jour.,  Jan.) ;  Blackburn  (Jour.  Amer. 
Med.  Assoc,  Mar.  31,  '88).  Cases  of 
marked  involvement  of  adrenals  failing 
in  the  symptoms  or  bronzing:  Virchow 
(Berliner  klin.  Woch.,  Apr.  29) ;  La- 
marque  (Jour,  de  M6d.  de  Bourdeaux, 
May  5) ;  West  (Brit.  Med.  Jour.,  Nov. 
9);  Perry  (Brit.  Med.  Jour.,  Oct.  21); 
Griffiths  (Brit.  Med.  Jour.,  Feb.  2,  '89). 
Girode  (Bull,  de  la  Soc.  Anat.,  Apr.); 
Barth  (London  Medical  Recorder,  May 
20);  CouDsell  (Lancet,  May  3)  ;  Vaughan 
(Brit.  Med.  Jour.,  Kov.  15) ;  Cagliati 
(Eiforma  Medica,  No.  6) ;  Jacquemard 
(La  Loire  Medicale,  Aug.  15);  Ritchie 
(Edinburgh  Med.  Jour.,  July,  '90),  and 
others. 

Case  of  Addison's  disease  without  pig- 
mentation. At  the  necropsy  each  suprar- 
enal body  was  found  to  be  enlarged  and 
adherent  to  the  surrounding  parts,  and 
thickly  studded  with  tubercles  of  the 
size  of  peas,  some  of  which  had  softened 
in  their  centres  and  contained  pus. 
There  was  no  apparent  implication  of  the 
solar  plexus.  J.  B.  Bradbury  (Lancet, 
Oct.  3,  '96). 

Addison's    disease   with    phthisis   pul- 
monalis  and  a  typical  pigmentation   of 
the  skin,  consisting  of  melanoderma  with 
symmetrical  patches  of  leucoderma.     C. 
0.  Hawthorne  (Glasgow  Med.  Jour.,  Oct., 
'96). 
In  addition  to  marked  disturbance  of 
the  functions  of  the  respiratory,  cardiac, 
and  splanchnic  nerve,  as  indicated  by 
shortness  of  breath,  irregular  action  of 
the  heart,  and  frequent  gastric  disturb- 
ances, a  few  cases  have  been  recorded  in 
which  delirium,  coma,  or  epileptoid  con- 
vulsions occurred  near  the  fatal  termina- 
tion.   Von  Jaksch  has  attributed  these 
sj'mptoms  to  acetonuria. 

Case  of  Addison's  disease  in  a  man, 
aged  57,  who  suiTered  for  months  from 
violent  attacks  of  delirium,  convulsions, 
and  eventually  coma  and  death.  The 
urine  was  always  free  from  albumin. 
Later  attacks  were  followed  by  coma, 
and,  though  treated  with  bleeding  and 
injection  of  (artificial)  serum,  he  died. 
The  necropsy  showed  oedema  of  the  cere- 


134 


ADDISON'S  DISEASE.    DIAGNOSIS. 


bral  meninges,  pericellular  and  perivas- 
cular increase  of  leucocytes  in  the  brain- 
cortex,  globules  of  myelin  in  the  white 
substance,  and  disseminated  sparse  nerve- 
degeneration  in  the  posterior  and  lateral 
spinal-cord  columns.  A  toxic  agent  re- 
sulting from  the  Addison's  disease  looked 
upon  as  the  cause  of  the  encephalopathy. 
Klippel  (Soc.  de  Neurol,  de  Paris,  Dec.  7, 
'99). 

Case   in  a   man   of  46   in  which   peri- 
tonitis-like symptoms  attended  the  final 
stage   of   addison's    disease.      The    abdo- 
men was  flat  and  palpation  was  painful 
in  the  epigastrium,  but  it  was  tympanitic 
everywhere.       He     vomited     frequently. 
The  diagnosis  had  been  in  great  doubt, 
but  a  malignant  tumor  along  the  gastro- 
intestinal   tract    was    suspected.      Post- 
mortem examination  showed  caseation  of 
both  suprarenal  glands,  with  swelling  of 
the  lymph-glands  and  brown  atrophy  of 
the  heart.     No  other  changes   of  much 
importance    wei'e    found.      Some    small, 
brownish  spots  were   found  on  the  left 
temple,  on  the  under  lip,  and  a  few  on 
the  upper  lip.    There  was  no  tuberculosis 
anywhere,    excepting   in   the    suprarenal 
gland.     A  diagnosis  of  Addison's  disease 
is  justified  with  this  peculiar  peritonitis- 
like symptom-complex  if  the  conditions 
cannot     otherwise    be     explained,     even 
though  all  other  symptoms  of  Addison's 
disease  are  absent.    Zaudy   (Zeit.  f.  klin. 
Med.,  B.  38,  H.  4,  5,  6,  1900). 
The    temperature    during    the    whole 
progress  of  the  disease  seldom  rises  above 
the  natural,  and  in  the  advanced  stage 
is  often  decidedly  below.     Eoux  men- 
tions a  case  in  which  the  temperature 
was  only  32.5°  C.  (90.5°  F.)  four  hours 
before  death.     Again,  in  the  advanced 
stage  of  many  cases  the  hands  and  feet 
are  uncomfortably  cold,  and  the  asthenia 
so    profound   that   the    patient    cannot 
maintain  the  erect  position  without  ver- 
tigo, cardiac  palpitation,'  or  syncope. 

The  disease  usually  runs  its  course 
and  terminates  in  death  in  from  one  to 
three  years.  A  few  cases  are  on  record 
that  terminated  in  six  months,  and,  per- 
haps,  a   larger  number  that   were   pro- 


tracted to  eight  and  ten  years.  Those 
of  longer  ditration  have  generally  been 
characterized  by  repeated  periods  dur- 
ing which  they  remained  stationary  for 
several  months  at  a  time. 

[One  such  well-marked  case  came 
under  my  own  observation.  The  patient, 
aged  about  35  years,  had  been  exposed 
to  much  hard  service  and  confined  air  on 
board  of  one  of  the  naval  monitors  in 
active  service  during  the  war,  between 
1861  and  1864.  Some  symptoms  of  the 
disease  were  manifested  as  early  as  in 
1865,  but  they  made  slov/  progress,  and 
appeared  to  have  several  periods  of  re- 
maining stationary,  and  did  not  termi- 
nate fatally  until  1875:  a  period  of  ten 
years.  During  the  last  year  he  had  been 
unable  to  walk  more  than  a  few  steps 
without  feelings  of  extreme  exhaustion, 
and  the  final  collapse  resulted  from  pro- 
tracted diarrhoea  and  vomiting.  Large 
bronzed  spots  were  on  his  forehead, 
temples,  backs  of  his  hands,  and  still 
more  over  the  front  part  of  his  chest  and 
abdomen.  Like  most  cases  of  this  dis- 
ease, his  emaciation  was  not  extreme, 
though  the  haemoglobin  was  notably 
diminished.     N.  S.  Davis.] 

Addison's  disease  may  terminate  in 
sudden  death.  Case  in  which  the  patient 
was  supposed  to  be  suffering  from  ma- 
larial cachexia  and  died  in  syncope. 
Autopsy  revealed  the  true  nature  of  the 
disease.  Letulle  (Bull,  de  la  Soc.  Anat., 
No.  6,  '94). 

Death  two  months  after  the  onset  of 
symptoms  in  a  case  in  which  one  of  the 
capsules  presented  an  old  tuberculosis, 
while  in  the  other  there  were  only  recent 
granulations.  Death  hastened  by  inter- 
current erysipelas.  Mouisset  (Lyon  M§d., 
May  27,  '94). 

Diagnosis. — The  presence  of  increased 
pigmentation  of  portions  of  the  skin  or 
mucous  membranes,  with  progressive 
asthenia,  frequent  gastric  disturbances, 
and  cardiac  weakness  constitute  the  chief 
diagnostic  features  of  melasma  suprar- 
enale, or  Addison's  disease.  Increased 
pigmentation  alone  is  not  sufficient  to 
justify  a  diagnosis  of  this  affection. 


ADDISON'S  DISEASE.     DIAGNOSIS. 


135 


Possibility  of  diagnosing  Addison's 
disease  wlien  the  characteristic  discolor- 
ation of  the  skin  and  mucous  membranes 
is  absent:  high-tension  pulse  or  a  very 
striking  difference  in  tension  between 
the  peripheral  pulse  and  that  in  the 
abdominal  aorta.  Neusser  (Med.  News, 
Sept.  IS,  '97). 

Case  of  Addison's  disease  in  a  phthis- 
ical man  in  whom  hot  applications  or 
mustard  plasters  caused  pigmentation. 
These  applications,  kept  up  a  week, 
caused  marked  pigmentation  upon  the 
abdominal  wall,  the  right  hip,  the 
shoulders,  and  the  calves.  Slight  pig- 
mentation appeared  spontaneously  upon 
the  patient's  forehead  before  these  ex- 
periments were  tried.  The  same  ex- 
periments produced  pigmentation  upon 
a  patient  with  Pott's  disease,  in  whom 
the  autopsy  showed  tuberculosis  of  the 
suprarenal  capsules.  Jacquet  and  Tre- 
molieres  (Bull,  et  Mem.  de  la  Soc.  M6d. 
des  Hopitaux  de  Paris,  July  25,  1901). 

Bronzed  spots  have  been  found  in  con- 
nection with  a  variety  of  malignant  and 
other  growths,  especially  in  the  abdomen 
and  pelvis,  with  some  cases  of  diabetes, 
exophthalmic  goitre,  and  also  in  cases  of 
pitlmonary  and  peritoneal  tuberculosis. 

Case  in  which  there  was  no  tendency 
on  the  part  of  the  discrete  pigmented 
area  to  run  together  and  become  diffuse. 
The  patches  of  pigmentation  remained 
isolated  throughout  up  to  the  time  of 
death.  These  oases  might  be  mistaken 
for  various  affections  in  which  pigmen- 
tation occurs:  idiopathic  multiple  sar- 
comata of  Kaposi,  xeroderma  pigmen- 
tosum, pigmented  lesions  following  syph- 
ilis, and  lentigines.  Trebitsch  (Zeit.  f. 
klin.  Med.,  B.  32,  S.  163,  '97). 

Pigmentation  of  mucous  membranes 
generally  considered  diagnostic  of  Addi- 
son's disease  seems  to  be  found  under 
other  conditions.  It  appears  to  occur  in 
some  cases  as  mere  accident  without  ob- 
vious cause;  it  may  also  be  associated 
with  chronic  gastric  diseases,  such  as  car- 
cinoma. Two  cases  of  abdominal  disease 
in  which  pigmentation  was  found  on 
mucosa  of  mouth.  In  first  case  diagnosis 
lay  between  cirrhosis  of  liver  and  chronic 


peritonitis ;  in  second  there  was  cholan- 
gitis due  to  gall-stones,  with  tubercular 
disease  of  lung  and  testicles.  In  neither 
could  Addison's  disease  be  absolutely  ex- 
cluded, but  group  of  symptoms  by  which 
it  is  distinguished  did  not  occur.  Nor 
can  occurrence  of  this  group  be  relied  on 
as  sure  indication  of  disease  of  supra- 
renal bodies.  Case  noted  in  which  weak- 
ness, anorexia,  anasmia,  vomiting,  and 
diarrhoea  were  all  present,  but  autopsy 
showed  only  chronic  gastric  catarrh 
without  affection  of  suprarenals.  In  this 
case  there  was  no  pigmentation.  Schultze 
(Deutsche  med.  Woeh.,  No.  46,  '98). 

Addison's  disease  is  not  the  only  dis- 
ease in  which  the  condition  of  body 
presents  discoloration  of  skin.  A  fair 
percentage  of  cases  also  runs  its  course 
without  bronzing.  Addison's  disease 
must  be  diagnosed  by  exclusion  of  ab- 
dominal cancer,  tubercle  or  lymphoma, 
tuberculosis  of  peritoneum,  pernicious 
ansemia,  and  others,  as  sun-bronzing, 
vagabond's  disease,  melasma  gravidarum, 
amyloid  kidney,  pulmonary  tuberculosis, 
yellow  fever  and  malarial  fevers,  heredi- 
tary bronzing,  arsenic  long  continued, 
diabete  bronze  of  the  French,  pellagra  in 
the  chronic  pigmentary  form,  Hodgkin's 
disease,  chronic  hepatic  disease,  and  con- 
stipation in  sedentary  patients.  A.  J. 
Lartigau  and  W.  H.  Happel  (Albany 
Med.  Annals,  Feb.,  '99). 

On  the  other  hand,  a  few  cases  have 
been  recorded  in  which  there  was  pro- 
found asthenia,  severe  gastric  disturb- 
ances, irregular  and  weak  pulse,  and 
early  death  from  syncope,  when  the  au- 
topsy revealed  both  suprarenal  bodies 
much  enlarged  from  caseous  and  tuber- 
culous degeneration,  but  no  pigmenta- 
tion or  bronzed  spots  on  either  skin  or 
mucous  surface.  Letulle  reported  a  case 
of  this  kind  in  1894.  The  patient  was 
supposed  to  be  suffering  from  malarial 
cachexia,  but  died  suddenly  from  syn- 
cope, and  "the  autopsy  showed  the  two 
capsules  to  be  transformed  into  fibro- 
caseous  blocks  as  large  as  a  mandarin 
orange."    There  is  at  present  no  known 


136 


ADDISON'S  DISEASE.    ETIOLOGY. 


reliable  mode  of  completing  the  diag- 
nosis of  such  cases  during  the  life  of  the 
patient. 

Direct  relation  between  diseases  of  the 
adrenals  and  bronzing  of  the  skin  de- 
nied. Case  where  one  suprarenal  body 
was  intact,  the  bronzing  nevertheless  ap- 
pearing. Two  cases  in  which  extensive 
tuberculosis  of  both  adrenals  was  present 
without  a  trace  of  dermal  discoloration. 
Where  there  is  discoloration  there  is  ex- 
tensive disease  of  the  nerves  and  ganglia 
of  the  abdominal  sympathetics.  Lancer- 
eaux  (Arch.  Ggn.  de  M6d.,  Jan.,  '90). 

A  similar  view.  Nothnagel  (Med. 
Press  and  Circular,  Jan.  12,  19,  '90). 

Discovery  of  a  pigmented  body,  the 
size  of  the  head  of  a  large  black  pin,  and 
presenting  the  complete  histology  of  a 
suprarenal  capsule  in  contact  with  the 
semilunar  ganglion.  Pilliet  (Bull,  de  la 
Soc.  Anat.,  No.  10,  '91). 

The  true  origin  of  the  bronzing  may 
still  be  said  to  be  unknown,  although 
several  plausible  theories  have  been  ad- 
vanced. In  the  cutis  there  are  chroma- 
tophorous  cells,  which,  as  is  the  case  in 
the  frog  and  chamelion,  are  under  direct 
nervous  control,  and  they  yield  an  ex- 
cess of  pigment  of  the  Malpighian  layer 
under  certain  conditions  of  nervous  dis- 
order.    Raymond   (Lancet,  July  2,  '92). 

Examination  of  the  skin  in  one  case. 
Coloring  composed  of  pigmented  clas- 
matocytes,  A\'hich,  after  penetrating  by 
migration,  fix  themselves  upon  the  sup- 
porting elements  of  the  derma.  Ch. 
Audry  (Le  Midi  Medical,  July  29,  '94). 

Masses  of  medullary  cells  and  even 
buds  of  the  substance  of  the  suprarenal 
capsules  in  the  interior  of  veins,  more 
frequently  in  the  medullary  than  in  the 
cortical  substance  found  in  man.  The 
same  peculiarities  were  noted  in  the 
horse,  ox,  pig,  and  sheep.  The  medullary 
tubes,  the  central  portion  of  which  is 
filled  with  brown,  hyaline  masses  se- 
creted by  the  double  row  of  cells  seen  on 
their  interior,  project  into  the  lumen  of 
the  veins,  at  this  point  deprived  of  their 
endothelial  covering.  Conclusion  that 
the  brown,  hyaline  masses  are  secreted 
by  the  suprarenal  capsules,  and  that  they 
are  carried  into  the   circulatory  stream 


after  penetrating  into  the  interior  of  the 
veins.  P.  Manasse  (Revue  des  Sciences 
M6d.,  July  15,  '94). 

The  melanodermia  of  Addison's  disease 
is  to  be  observed  whenever  the  periphery 
of  the  organ,  the  cortex,  the  nerve-fila- 
ments, or  the  ganglia  of  the  region  are 
involved.  On  the  other  hand,  it  is  diffi- 
cult to  distinguish  which  phenomena  are 
due  to  toxaemia.  Bedford  Fenwick, 
Greenhow,  Jurgens,  Kalindero,  BabSs 
(Brit.  Med.  Jour.,  Mar.  30,  Apr.  6,  '95). 

Etiology.  —  Well-marked  cases  of  me- 
lasma suprarenale  are  of  comparatively 
rare  occurrence  in  this  country.  Of  the 
cases  on  record,  much  the  larger  number 
were  in  persons  between  the  ages  of  20 
and  40  years;  and  more  than  60  per 
cent,  were  in  the  male  sex.  Greenhow 
collected  183  cases,  of  which  119  were 
males  and  64  females.  BelaiefE  has 
recorded  one  congenital  case,  the  child 
living  eight  weeks  after  birth,  the  skin 
presenting  a  yellowish-gray  color,  and  an 
autopsy  showed  the  suprarenal  capsules 
enlarged  and  filled  with  cysts.  Another 
case  has  been  reported  in  a  child  only 
8  days  old.  Its  skin  was  "mottled  and 
yellowish  brown."  An  autopsy  revealed 
enlargement  and  congestion  of  the  mid- 
dle third  of  the  right  suprarenal  capsule, 
and  hsemorrhage  with  caseous  degenera- 
tion in  the  left. 

Records  collected  of  48  cases  of  Addi- 
son's disease  occurring  during  childhood. 
Youngest  child  was  7  days,  eldest  14  Vj 
years.  The  affection,  almost  invariably 
due  to  tuberculosis,  is  usually  first  mani- 
fested by  vague  symptoms,  such  as  weak- 
ness, ansemia,  loss  of  weight,  gastro- 
intestinal symptoms,  nausea,  vomiting, 
and  diarrhcea.  Pain  and  pigmentation 
are  quite  uncommon  in  children.  Con- 
vulsions are  usual,  intermissions  fre- 
quently occur,  and  the  disease  pursues  a 
more  rapid  course  than  in  adults. 
Dezirot  (Jour,  de  M«d.,  Aug.  28,  '98). 

Addison's  disease  in  a  3-year-old  child. 
It  was  taken  quite  suddenly  with  diar- 
rhcea, gastric   disturbance,   and  prostra- 


ADDISON'S  DISEASE.    PATHOLOGY. 


137 


tion.  At  the  end  of  three  days  asthenia 
was  marked,  and  there  were  complaints 
of  pain  in  the  upper  part  of  the  abdomen 
and  lumbar  region.  The  vomiting, 
elevated  temperature,  and  the  character 
of  the  pulse  pointed  to  a  peritonitis.  A 
slight  pigmentation  of  the  abdomen  was 
all  that  suggested  Addison's  disease,  but 
the  previous  history  of  the  patient  did 
not  support  such  a  diagnosis.  At  the 
autopsy  an  ancient  tuberculosis  of  the 
suprarenal  capsules  was  found.  Peyer's 
patches  were  swollen,  but  not  ulcerated. 
The  spleen,  which  was  enlarged,  fur- 
nished a  pure  streptococcic  culture.  The 
case  is  interesting  from  what  appears  an 
acute  Addison's  disease,  the  more  pro- 
nounced symptoms  of  which  developed 
coincidently  with  a  general  streptococcic 
infection.  Netter  and  Nattan-Larrier 
(La  Presse  M6d.,  May  2,  1900). 
On  the  other  hand,  one  or  more  cases 
have  heen  recorded  as  occurring  as  late 
in  life  as  70  years. 

As  predisposing  causes,  we  find  enu- 
merated excessive  physical  labor,  men- 
tal anxiety  and  depression,  caries  of  the 
spine,  confinement  in  damp  and  ill-ven- 
tilated rooms,  insufficient  food,  blows 
upon  the  abdomen,  and  tuberculosis  of 
the  peritoneum.  Greenhow  claimed  that 
nine-tenths  of  the  cases  collated  by  him 
had  occurred  among  the  laboring  classes. 
Nearly  all  the  conditions  mentioned  as 
predisposing  causes  are  the  same  as  are 
generally  alleged  to  predispose  to  pulmo- 
nary and  other  varieties  of  tuberculosis. 
The  more  efficient  or  direct  cause  of  the 
disease  imder  consideration  appears  to 
be  an  interruption  of  the  functions  of 
the  suprarenal  capsules.  According  to 
Lewin,  some  degree  of  structural  disease 
of  these  capsules  is  found  in  88  per  cent, 
of  all  the  cases,  and  the  most  frequent  of 
these  changes  is  tubercular. 

Tuberculosis  is  the  most  frequent  and 
important  change  in  the  adrenals  in 
Addison's  disease.  The  various  other 
changes  in  these  bodies — as  chronic  in- 
flammation, caseation,  or  calcareous  infil- 


tration— are  to  be  regarded  only  as  the 
different  results  of  the  tuberculosis. 
Alezais  and  Arnaud  (Eevue  de  M6d., 
Apr.,  '91). 

Typical  case  in  which  the  suprarenals 
were  both  enlarged  and  cheesy,  the  ab- 
dominal sympathetics  being  enlarged  and 
red  to  the  naked  eye,  associated  with 
pulmonary  tuberculosis  and  Pott's  dis- 
ease of  the  spine.  Tyson  (Univ.  Med. 
Mag.,  Sept.,  '91). 

It  has  been  proved  that  the  etiological 
factors  underlying  Addison's  disease  are 
not  dependent  upon  the  presence  or  ab- 
sence of  the  adrenals  alone.  The  chief 
symptoms  of  Addison's  disease  can  be 
produced  by  lesions  of  ganglia  in  close 
association  with  the  adrenal  blood- 
supply.  A.  F.  Jonas  (Annals  of  Surg., 
Apr.,  '98). 

Analysis  of  several  cases  tending  to 
suggest  that  certain  toxic  substances, 
such  as  pyrocatechin,  phosphoric  and  lac- 
tie  acids,  are  developed  in  the  intestines 
and  muscles,  and  that  these  are  altered 
in  the  suprarenals  and  there  prepared  for 
excretion.  When  for  any  reason  the 
suprarenal  tissue  is  destroyed,  these  sub- 
stances will  remain  in  the  system  and 
lead  to  a  chronic  intoxication.  I.  Huis- 
mans  (Munch,  med.  Woch.,  Mar.  27, 
1900). 

History  of  a  family  in  w'hich  the 
mother  with  her  first  pregnancy  had  be- 
gun to  show  pigmentation.  With  each 
subsequent  pregnancy  she  had  become 
more  pigmented  and  more  depressed,  and 
at  the  time  of  the  report  she  had  marked 
disturbance  of  the  gastro-intestinal  tract, 
with  irregular  pains,  attacks  of  giddiness 
and  syncope,  and  numerous  almost  black 
spots  resembling  moles  over  the  body. 
Four  children  showed  similar  symptoms, 
decreasing  in  degree  and  severity  directly 
with  their  youth.  The  cases  were  dis- 
tinctly Addison's  disease,  but  tuberculo- 
sis might  have  existed  in  the  whole 
family  and  have  involved  the  suprarenal 
glands.  Family  involvement  in  Addison's 
disease  has  been  rarely  noted.  R.  A. 
Fleming  and  J.  Miller  (Brit.  Med.  Jour., 
Apr.  28,  1900). 
Pathology.  —  The  post-mortem  exam- 
ination of  the  case  reported  by  Jonas, 


138 


ADDISON'S  DISEASE.     PATHOLOGY. 


in  addition  to  the  bronzed  spots  on  the 
surface,  the  cavities  of  the  heart  moder- 
ately filled  with  blood  only  partially  co- 
agulated; the  liver  and  spleen  of  natural 
size  and  color;  the  mucous  membrane 
of  the  stomach  and  ileum  congested, 
softened  in  some  places  with  abrasions; 
and  the  suprarenal  capsule  much  en- 
larged. No  other  morbid  appearances 
were  noticed  in  the  abdominal  viscera. 
An  incision  through  the  centre  of  the 
suprarenal  capsules  revealed  a  central 
caseous  mass  in  each,  of  the  consistence 
of  new  cheese,  about  thirty  millimetres 
in  diameter,  inclosed  in  a  sac  of  gray, 
fibrous  tissue,  with  some  spots  and 
streaks  of  yellowish  color.  On  the  sur- 
face of  the  caseous  mass  next  to  the 
surrounding  capsule  was  a  thin  layer  of 
a  creamy  consistence,  and  the  fibrous 
capsule  under  the  microscope  showed 
the  presence  of  fusiform,  lymphoid,  and 
large  granular  or  giant  cells  in  consid- 
able  numbers.  Both  capsules  presented 
the  same  appearance  and  were  undoubt- 
edly good  specimens  of  tuberculous  dis- 
ease. 

The  two  most  constant  anatomical 
changes  found  in  Addison's  disease  are 
the  pigmented  spots  consisting  of  gran- 
ular pigment  deposited  in  the  deeper 
layers  of  the  rete  Malpighi  and  the 
caseous  or  tuberculous  degeneration  of 
the  suprarenal  capsules.  Of  375  cases 
collected  by  Lewin,  in  288  the  suprar- 
enals  were  found  tuberculous,  and  in 
many  other  cases  they  were  affected  with 
inflammation,  cysts,  atrophy,  carcinoma, 
or  sarcoma. 

Case  in  which  the  tubercular  nature 
of  the  lesions  in  the  suprarenal  bodies 
was  demonstrated.  Death  took  place 
with  absolute  suddenness.  The  autopsy 
showed  slight  evidence  of  tuberculosis  of 
the  lung.  One  suprarenal  capsule  pre- 
sented a  very  pronounced  caseation,  and 
was  large  and  lumpy.    In  the  other  the 


lesion  was  much  less  pronounced.  The 
capsule  was  not  greatly  enlarged,  but  its 
normal  tissue  had  disappeared,  and  its 
place  was  taken  by  a  general,  homo- 
geneous, tough  tissue,  in  which  were  a 
few  caseous  centres.  Microscopical  ex- 
amination demonstrated  that  the  lesion 
was  tubercular,  and  there  were  tuber- 
cular bacilli  in  the  capsules.  The  bacilli 
were  not  numerous,  but  unequivocal. 
Joseph  Coats  (Glasgow  Med.  Jour.,  Aug., 
'92). 

Five  cases  of  Addison's  disease  which 
had  been  examined,  first  clinically  and 
afterward  post-mortem.  In  all  of  them 
the  suprarenal  capsules  were  found  dis- 
eased. In  four  they  were  extremely 
tuberculous,  three  showing  the  disease 
on  both  sides,  and  one  on  one  side  only. 
In  the  fifth  case  there  was  a  carcinoma- 
tous degeneration  of  the  left  suprarenal 
as  well  as  left-sided  pulmonary  cancer. 
Posselt  (Centralb.  f.  klin.  Med.,  Feb.  5, 
'95). 

Case  of  Addison's  disease  in  a  boy,  14 
years  old,  suffering  from  old  pulmonary 
tuberculosis,  with  recent  miliary  out- 
break; considerable  epigastric  pain  dur- 
ing life.  No  pigmentation  of  skin.  Post- 
mortem disclosed,  in  addition  to  lung 
condition,  enlarged  and  pigmented  bron- 
chial glands,  enlarged  and  firm  mesen- 
teric glands,  with  congestion  of  liver, 
kidneys,  spleen,  and  intestines.  Capsules 
of  suprarenal  bodies  were  thickened  and 
adherent  to  surrounding  tissues.  Each 
suprarenal  body  was  four  times  normal 
size.  On  section  they  were  caseous,  and 
contained  cretaceous  nodules.  Micro- 
scopically mesenteric  glands  showed 
small-cell  infiltration  without  giant-cells. 
Periphery  of  suprarenals  was  rich  in 
typical  small  tubercles,  many  containing 
large,  multinucleated  giant-cells.  Signs 
considered  of  diagnostic  importance  were 
extreme  asthenia,  emaciation,  anorexia, 
vomiting,  abdominal  pain,  and  small, 
rapid  pulse.  J.  Anderson  (Lancet,  June 
18,  '98). 

Autopsy  of  a  case  of  Addison's  disease 
in  a  girl  who  had  had  tuberculous  cer- 
vical glands  and  tuberculosis  of  the 
lungs,  with  brownish  skin  and  extreme 
ansemia.       Both     adrenal    bodies     were 


ADDISON'S  DISEASE.    PATHOLOGY. 


139 


found  infected  with  tuberculosis.  The 
object  of  the  adrenal  bodies  is  to  absorb 
certain  toxic  substances  manufactured 
in  the  intestines.  Huismana  (Miinehener 
med.  Woeh.,  Apr.  2,  1901). 

Next  in  frequency  to  the  suprarenal 
capsules,  the  ganglia  of  the  sympathetic 
■system  of  nerves  have  been  found  altered 
in  structure,  especially  in  the  neighbor- 
hood of  the  capsules.  In  many  eases 
structural  changes  have  been  found  to 
co-exist  in  both  the  capsules  and  the 
ganglia  of  the  sympathetic  in  the  same 
patients. 

On  the  other  hand,  a  few  cases  have 
been  reported  presenting  all  the  clinical 
symptoms  of  Addison's  disease,  in  which 
the  autopsy  failed  to  find  any  structural 
changes  in  either  the  suprarenal  capsules 
or  the  nerve-ganglia. 

Case  in  which  the  typical  changes  were 
encountered,  and  in  which  there  was 
found  a  chronic  spinal  sclerosis  of  the 
posterior  root-zones,  with  a  neuritis 
attacking  especially  the  posterior  roots 
of  the  spinal  nerves.  Marked  by  a  swell- 
ing of  the  axis-cylinders,  their  rupture 
at  places,  and  a  multiplication  of  cells. 
Kallendro  and  Babes  (La  Seniaine  Med., 
Peb.  22,  '89). 

[The  cases  of  adrenal  involvement 
without  co-existing  pigmentary  changes 
lend  considerable  weight  to  the  asser- 
tions of  those  pathologists  who  find 
Addison's  disease  rather  a  disease  of 
nervous  origin  than  one  involving  a 
glandular  organ.  This  opinion  is  further 
strengthened  by  the  finding  of  pigment- 
ary changes  in  cases  presenting  no 
demonstrable  change  in  the  adrenals. 
Another  point  of  no  slight  weight  may 
be  taken  in  the  suggestion  of  .Jiirgens, 
that  at  least  a  certain  class  of  pigmented 
instances  are  due  to  peripheral  nervous 
irritation,  possibly  from  epithelial  de- 
generation or  actual  external  irritation, 
mostly  met  about  the  flexures,  folds,  and 
in  the  face,  from  exposure.  This  last 
suggestion  is  further  borne  out  physio- 
logically from  the  pigmentation  often 
caused  by  the  constant  wearing  of  even 


non-metallic  objects,  as  buttons,  next  the 
skin. 

The  opposite  view — i.e.,  of  glandular 
destruction  —  cannot,  however,  be  set 
aside,  numerous  careful  observations  and 
the  results  of  various  experimenters  offer- 
ing weight  in  this  direction. 

As  to  the  nature  of  growth  found  in 
the  suprarenals,  there  can  be  but  little 
doubt  that  other  new  formations  than 
tuberculosis  are  attended  by  the  com- 
plex of  symptoms  of  Addison's  disease. 
TY.SON"  and  Smith,  Assoc.  Eds.,  Annual, 
'89.] 

Investigations  upon  rabbits  and  dogs 
showing  that  the  adrenals  stand  in  inti- 
mate relation  with  the  central  nervous 
system,  and  that  their  affection  is  the 
cause  of  the  train  of  phenomena  known 
as  Addison's  disease.  Tizzoni  (London 
Med.  Recorder,  Feb.,  '90). 

Case  in  ^¥hich,  associated  with  the 
ordinary  symptoms,  there  occurred  a 
sudden  attack  of  bromidrosis,  indicating 
a  rather  serious  involvement  of  the 
sympathetic  nervous  system.  Ohmann- 
Dumesnil  (Atlanta  Med.  and  Surg.  Jour., 
July,  '90). 

Six  cases  of  adrenal  caseation,  in  some 
of  which  there  was  distinct  round-celled 
infiltration  of  the  semilunar  ganglia 
without  bronzing  of  the  skin.  Addison's 
disease  cannot  be  said  to  be  directly  due 
to  changes  in  the  sympathetic  abdominal 
ganglia,  although,  perhaps,  this  or  that 
symptom  of  the  affection  may  depend 
on  such  involvement  of  the  sympathetic 
ganglia.  Von  Kahlden  (Miinch.  med. 
■Woch.,  June  23,  '91). 

Not  the  great  sympathetic  nerves  and 
ganglia,  not  the  suprarenal  capsules 
themselves,  but  the  pericapsular  nerve- 
ganglia  constitute  the  especial  starting- 
point  for  the  development  of  the  symp- 
toms of  Addison's  disease.  Alezais  and 
Arnaud   (La  Semaine  Mgd.,  Oct.  7,  '91). 

Four  autopsies  suggesting  that  the  dis- 
ease is  due  to  irritation  of  the  abdominal 
sympathetic  from  direct  lesion  of  the 
nerve,  its  ganglia,  or  the  suprarenal  cap- 
sules. This  lesion  is  most  frequently 
primary  or  secondary  to  tuberculosis  of 
the  capsules  with  secondary  involvement 
of  the  sympathetic.     In  less  than  20  per 


140 


ADDISON'S  DISEASE.     PATHOLOGY. 


cent,  it  is  not  tuberculous,  and  in  12 
per  cent,  of  the  cases  the  capsules  remain 
normal.  Thompson  (Amer.  Jour,  of  the 
Med.  Sciences,  Oct.,  '93). 

To  be  regarded  as  a  functional  whole, 
the   cortex   and   the  medulla   doing   the 
same    work,    but    in    unequal    degrees. 
Atrophy  of  the  suprarenal  capsules  oc- 
curs normally  in  old  age,  but  may  occur 
earlier  in  life  and  cause  Addison's   dis- 
ease.    Hsemorrhage    into   the   substance 
of  the  gland  may  be  due  to  traumatism 
either  later  in  life  or  in  infants  at  birth. 
Fatty  and  lardaceous   degenerations  oc- 
cur.     The   glands   have    been    found   to 
contain  ej'sts.     Out  of  one  hundred  and 
thirty-one  cases  in  which  death  was  due 
to  tuberculosis,  the  glands  were  tuber- 
culous   in    eighteen,    without,    however, 
there  being  any  signs  of  Addison's  dis- 
ease.    Rolleston    (Lancet,  Mar.  23,  '95). 
The    primary    morbid    conditions    or 
processes  on  which  depend  the  develop- 
ment of  the  clinical  phenomena  of  Ad- 
dison's  disease   have   not   yet   been   so 
clearly  demonstrated  as  to  remove  the 
subject  from  the  fields  of  controversy  or 
doubt. 

Much  the  larger  number  of  writers 
incline  to  agree  with  Dr.  Addison,  who 
ascribed  all  the  essential  symptoms  and 
results  of  the  disease  to  interruption  of 
the  function  of  the  suprarenal  capsules 
caused  by  some  form  of  disease  in  those 
organs.  Those  holding  this  view  assume 
that  these  bodies  either  destroy  some 
toxic  element  resulting  from  natural 
metabolic  changes  in  the  blood  or  tis- 
sues, or  secrete  and  return  to  the  blood 
some  substance  necessary  for  the  main- 
tenance of  health. 

Pyrocatechin,  found  in  the  medulla  of 
the  suprarenal  gland,  becomes  brown  in 
contact  with  air  or  alkaline  tissues.  It 
is  converted  in  Addison's  disease  into  a 
poisonous  compound  on  leaving  the  su- 
prarenal body  and  entering  the  circu- 
lation. In  health  the  elimination  of 
pyrocatechin  occurs  through  the  agency 
of  the  sympathetic  ganglion-cells.  The 
debility,   etc.,   are   the   signs   of   chronic 


poisoning  with  pyrocatechin:  an  auto- 
toxieation.  Miihlmann  (Miinehener  med. 
Woch.,  Feb.  16,  '96). 

Certain  changes  in  the  suprarenal  cap- 
sules— such  as  hypersemia,  hypertrophy, 
etc. — are  noted  when  certain  poisons  are 
introduced  into  the  system,  especially  if 
slowly  given:  cloves,  toluene-amin,  tox- 
ins of  bacilli,  etc.  (Eoux  and  Yersin, 
Roger,  Pilliet,  Charrin  and  Langlois.) 

The  toxic  power  of  the  extract  of 
suprarenal  capsules  was  noted  by  Foi 
and  Pellacani  (1884),  and  has  been  ex- 
amined since  then  by  many  authors.  It 
causes  a  rise  in  the  blood-pressure  com- 
bined with  slowing  of  the  heart.  (Cy- 
bulski,  Olivier  and  Schafer.) 

Capsules  which  are  affected  with 
hypei'ffimia  still  contain  the  principle 
which  gives  rise  to  the  above  effect  (not 
pyrocatechin) ;  but  capsules  hypertro- 
phied  to  double  or  more  their  original 
size  no  longer  contain  it.  P.  Langlois 
(Arch,  de  Phys.,  vol.  viii,  p.  152,  '96). 

The  suprarenal  capsules  are  intended 
for  the  destruction  of  the  red  blood-cor- 
puscles, which  give  up  their  haemoglobin 
to  the  medullary  cells  of  these  organs 
under  the  form  of  pigment.  Blood  poi- 
sons— such  as  formol,  aniline  products, 
mineral  poisons,  sodium  nitrate,  and 
uranium  nitrate  —  cause  congestion  of 
the  capsule,  excess  of  pigment  in  the 
cells  of  the  medullary  region,  and  haem- 
orrhages into  the  same  region.  The 
blood  passes  through  the  capsule  from 
the  centre  toward  the  periphery,  giving 
up  its  hfemoglobin  to  the  medullary  sub- 
stance or  to  the  deeper  portion  of  the 
cortical  substance.  When  the  gland  has 
taken  up  all  it  can,  other  mesodermic 
elements  assume  its  functions,  such  as 
white  blood-globules  and  connective  cells 
of  the  skin.  This  gives  rise  to  the  pig- 
mentation of  the  skin  in  certain  de- 
structive lesions  of  the  capsule.  A.  Pil- 
liet (Arch,  de  Phys.,  vol.  vii,  p.  555,  '96). 

Brown-Sequard  claimed  that  the  pig- 
ment derived  from  the  disintegration  of 
red  corpuscles  of  the  blood  was  destroyed 
in  the  suprarenal  capsules.  If  this  is 
true,  any  disease  affecting  them  suffi- 
ciently to  suspend  their  function  should 


ADDISON'S  DISEASE.    PATHOLOGY. 


141 


be  followed  by  increased  pigmentation 
and  possibly  give  rise  to  all  the  other 
symptoms  of  the  general  disorder. 

Two   cases  of  Addison's  disease:     one 
a  typical  instance  of  caseous  degenera- 
tion of  tlie  adrenals  with  melanoderma, 
tlie  other  one  of  malignant  disease  of  the 
suprarenals  without  discoloration  of  the 
skin.    In  both  cases  the  blood-count  was 
high.      In    the    first   the    red    corpuscles 
numbered  from  6,500,000  to  7,200,000;   in 
the    second,    5,400,000.      A.    A.    Christo- 
manos    (Berliner   klin.    Woch.,    Oct.    16, 
'99). 
Experiments  on  animals  for  the  pur- 
pose of  determining  the  real  functions 
of  the  suprarenal  bodies  by  several  in- 
vestigators  have   resulted    so    variously 
as  to  lead  to  contradictory  conclusions. 
After  total  extirpation  of  both  suprar- 
enal capsules  in  one  hundred  and  fifty- 
three  animals  no  changes  in  pigmenta- 
tion  or   other  symptoms   of  Addison's 
disease  vrere  observed.     (Nothnagel.) 

In  neither  of  these  cases,  however,  are 
we  informed  as  to  how  long  after  the 
extirpations  the  animals  were  kept  un- 
der observation.  On  the  other  hand, 
Tizzoni,  who  kept  rabbits  alive  two  and 
three-fourths  years  after  crushing  the 
adrenals,  claimed  that  pathological  pig- 
mentation and  some  multiple  degenera- 
tions in  the  spinal  cord  developed.  The 
experiments  of  Abelous  and  Langlois  also 
appear  to  prove  that  animals  deprived 
of  these  bodies  die  with  symptoms  of 
toxaemia. 

The  symptoms  of  the  affection  indicate 
an  intoxication,  the  experiments  of  Abe- 
lous and  Langlois  having  shown  that 
animals  deprived  of  the  capsules  die 
poisoned,  and  that  their  blood  shows  a 
special  toxicity.  If  a  small  portion  of 
the  suprarenal  parenchyma  be  retained, 
the  intoxication  is  neutralized  and  life 
remains  possible.  In  Addison's  disease, 
adynamia,  gastric  disturbances,  and  the 
terminal  symptoms  of  cardiac  collapse 
(hypothermia  and  coma)  appear  to  be 
purely  toxic  phenomena,  although  these 


have  not  always  been  provoked  with 
hypodermic  injections  of  suprarenal 
juice.  All  the  symptoms  do  not  depend 
upon  intoxication,  however,  the  pigmen- 
tation of  the  skin  and  mucous  mem- 
branes being  in  relation  to  lesions  of  the 
sympathetic.  Chaufi'ard  (La  Semaine 
M6d.,  Feb.  14,  '94). 

One  of  the  functions  of  the  capsules 
Is  to  destroy  a  part  of  the  used-up  red 
corpuscles.  If  this  excretory  or  depura- 
tive  function  is  interfered  with,  the  cir- 
culation of  the  decomposition  products 
of  hsemoglobin  causes  Addisonian  poison- 
ing. Role  attributed  to  the  medullary 
substance.  The  role  of  the  cortical  sub- 
stance is  that  of  furnishing  a  secretion 
that  is  taken  up  by  the  lymphatics,  and 
which  is  indispensable  to  the  needs  of 
the  organism.  Auld  (Brit.  Med.  Jour., 
May  12,  '94). 

[Auld  thus  appears  to  assign  to  the 
suprarenal  bodies  a  double  function.  N. 
S.  Davis.] 

The  suprarenal  bodies  elaborate  a  sub- 
stance which  has  a  very  powerful  action 
on  the  muscular  tissues  and  more  espe- 
cially on  the  muscular  coat  of  the  ar- 
teries. It  causes,  in  very  small  doses,  an 
enormous  heightening  of  the  blood-press- 
ure, dependent  upon  contraction  of  the 
peripheral  vessels,  due  to  a  direct  action 
of  the  substance  on  the  muscular  coat, 
and  not  to  any  action  on  the  medullary 
vasomotor  centre.  It  also  acts  directly 
on  the  heart,  producing  augmentation 
and  acceleration,  provided  the  vagi  are 
divided.  On  the  voluntary  muscles  its 
action  is  such  that  the  period  of  contrac- 
tion is  slightly  and  the  period  of  relaxa- 
tion greatly  prolonged.  On  respiration 
more  marked  effects  are  obtained  in  rab- 
bits than  in  dogs.  In  cases  of  Addison's 
disease  no  physiological  action  from  the 
extract  of  the  diseased  capsules  obtained. 
It  is  possible  that  the  phenomena  of  Ad- 
dison's disease  are  due  to  the  absence  of 
this  active  principle.  Schilfer  and  Oliver 
(Practitioner,  Sept.,  '95). 

Results  of  experiments  on  one  hun- 
dred and  nine  rats  from  which  both 
suprarenal  capsules  were  removed,  and 
others  in  which  these  bodies  were  cauter- 
ized  or   otherwise   inflamed.     After   the 


142 


ADDISON'S  DISEASE.    PATHOLOGY. 


lapse  of  a  few  months  a  large  number  of 
these  animals  showed  an  infiltration  of 
the  pigment  in  the  subcutaneous  cellular 
tissues,  in  the  lumbar  and  mesenteric 
glands,  in  the  peritoneum,  mesentery, 
liver,  spleen,  and  lungs.  Muscular  pare- 
sis had  developed  in  some  of  them  with 
increasing  asthenia;  and  the  injection  of 
an  extract  from  the  muscles  of  such  rats 
proved  fatal  to  other  rats.  Boinet  (La 
Semaine  M6d.,  No.  8,  '96). 

This  view  of  the  functions  of  the  cap- 
sules, in  connection  with  the  fact  that 
some  form  of  disease  has  been  found  in 
them  in  nearly  90  per  cent,  of  all  the 
cases  on  record,  certainly  points  directly 
to  interference  with  or  interruption  of 
such  functions  as  the  first  link  in  the 
chain  of  pathological  processes  consti- 
tuting the  disease  under  consideration. 

Another  class  of  writers  and  investi- 
gators, however,  finding  evidence  of 
structural  changes  in  a  considerable 
number  of  cases  of  Addison's  disease  in 
the  ganglia  of  some  parts  of  the  abdomi- 
nal sympathetic  system  of  nerves,  have 
claimed  that  these  changes  are  the  pri- 
mary pathological  steps,  and  that  all  the 
general  phenomena  result  from  trophic 
influences.  Prominent  among  those  ad- 
vocating this  view  are  Biesel,  Burgen, 
and  W.  G.  Thompson,  while  Alezais  and 
Arnaud  claim  that  the  primary  seat  is 
neither  in  the  ganglia  of  the  sympathetic 
nerves  nor  in  the  suprarenal  capsules 
proper,  but  in  the  pericapsular  nerve- 
ganglia  themselves. 

Case  in  which  there  was  a  sudden  and 
maniacal  attack  the  day  before  death, 
lasting  several  hours,  dissections  show- 
ing caseous  suprarenal  bodies  and  the 
thickening  and  matting  of  the  tissues  in 
the  neighborhood  of  the  semilunar  gan- 
glia and  solar  plexuses.  Lindsay  Steven 
(Lancet,  Oct.  31.  '96). 

Certain  vasodilator  fibres  run  in  the 
splanchnic  nerves  to  the  adrenals.  In 
the  dog  the  splanehnics,  after  traversing 
the   diaphragm,   give   off   on   each   side. 


before  they  enter  into  the  formation  of 
the  solar  plexus,  a  single  large  branch  to 
the  adrenals;  these  are  thought  to  con- 
tain the  chief  vasodilator  fibres,  since,  if 
divided,  stimulation  of  the  splanehnics 
in  the  thorax  is  Avithout  influence,  while 
stimulation  of  the  distal  extremities  of 
the  divided  nerves  is  followed  by  active 
hypersemia.  Arthur  Biedl  (Pfliiger's 
Arehiv,  June,  '97). 

The  theories  of  the  changes  in  the 
great  sympathetic  system  and  of  insuffi- 
ciency of  the  capsules  which  have  been 
opposed  to  one  another  as  an  explana- 
tion of  the  cause  of  Addison's  disease 
each  contain  some  truth,  but  are  too  ex- 
elusive.  Where  the  capsules  are  either 
absent  or  not  diseased,  only  the  nervous 
theory  can  be  upheld.  Clinical  research 
and  experiments  prove  that  pathological 
or  experimental  destruction  of  the  cap- 
sules acts  not  only  by  the  ascending  and 
secondary  degeneration  of  the  great  sym- 
pathetic and  its  ganglia,  but  also  by 
capsular  insufficiency. 

This  suppression  of  the  action  of  the 
capsules  favors  retention  in  the  blood, 
viscera,  and  muscles  of  toxic  products 
which  appear  to  play  a  certain  part 
either  in  the  formation  of  pigment  in 
the  blood  or  in  the  production  and  in- 
crease of  the  asthenia.  E.  Boinet  (Revue 
de  Med.,  Feb.,  '97) . 

In  this  connection  it  is  proper  to  state 
that  F.  Marino-Zucco,  Director  of  the 
Chemico-Pharmaceutical  Institute  of 
Genoa,  has  obtained  neurin  from  the 
normal  suprarenal  capsules  in  notable 
quantity,  and  has  detected  the  same  sub- 
stance in  the  urine  of  a  patient  with 
Addison's  disease.  This,  with  further 
experiments  with  neurin,  led  him  to  re- 
gard the  retention  of  this  substance,  on 
account  of  disease  of  the  capsules,  as  the 
probable  caitse  of  the  more  general  dis- 
order. The  results  of  the  more  recent 
active  investigations  concerning  the 
functions  of  the  thyroid  and  other  duct- 
less glands,  and  the  therapeutic  effects 
of  extracts  derived  from  them,  add  to 
the  probability  that  the  statement  we 


ADDISON'S  DISEASE.    PROGNOSIS.    TREATMENT. 


143 


have  quoted  from  Auld  will  be  found 
correct.  That  the  suprarenal  capsules 
contain  true  glandular  structure,  and 
also  an  abundance  of  nerve-ganglia  and 
filaments  connecting  freely  with  the  ab- 
dominal sympathetic  system  of  nerves, 
was  fully  demonstrated  by  Henle  and 
von  Brunn. 

The  existence  of  a  true  glandular 
structure  plainly  implies  a  secreting  or 
transforming  fimction,  the  suspension  of 
which  would  lead  to  some  kind  of  me- 
tabolic disorder,  while  the  close  nervous 
connection  with  the  sympathetic  would 
explain  the  coincident  gastro-intestinal 
disorders  and  progressive  asthenia.  This 
pathological  view  also  enables  us  to  see 
why  the  clinical  phenomena  constituting 
Addison's  disease  may  be  developed,  not 
exclusively  by  tuberculosis  or  any  one 
special  disease,  but  by  any  and  every 
morbid  condition  capable  of  persistently 
interrupting  the  natural  function  of  the 
suprarenal  bodies. 

Case   in  which   autopsy  revealed   eon- 
genital   absence    of   the   suprarenal   cap- 
sules.     No    other    lesions    were    found. 
Only  two  similar  cases  reported.    Patient 
was  24  years  old;    the  symptoms  were 
melanoderma,  pains,  progressive  asthenia, 
wasting,   cachexia,   and  gastro-intestinal 
disturbance.       Ended     fatally     in     ten 
months.     A.  Rispal   (Third  French  Med. 
Cong.;   N.  Y.  Med.  Record,  Sept.  19,  '97). 
Case  of  Addison's  disease  with  simple 
atrophy  of  the  adrenals  in  which,  though 
the   histological   changes  were   compara- 
tively slight,  the  symptoms  of  Addison's 
disease  were  well  marked  and  fatal.    The 
cutaneous   pigmentation   appeared    four- 
teen years  before  the  onset  of  the  pro- 
found  constitutional   symptoms.     Carlin 
Philips    (.Jour,   of  Exper.  Med.,  vol.  iv; 
Practitioner,  May,  1900). 
Prognosis.  —  Until  very  recently  the 
progno.?is  in  well-characterized  cases  of 
Addison's   disease   has  been   uniformly 
regarded  as  unfavorable.    It  is  true  that 
a  very  few  cases  of  recovery  have  been 


reported,  but  nearly  all  writers  of  the 
highest  aitthority  regard  such  as  ex- 
amples of  mistaken  diagnosis.  "An 
absolutely  fatal  prognosis  must  always- 
be  made.  In  all  these  cases  which  are 
recorded  as  having  been  cured  there 
exists  a  doubt  as  to  the  accuracy  of  the 
diagnosis."    (Merkel.) 

Osier,  in  1894,  declared  that  the  dis- 
ease was  fatal  in  every  case.  In  the 
meantime,  encouragement  by  the  results- 
of  the  use  of  the  thyroid  gland  or  ex- 
tracts from  the  same  in  cases  of  acrome- 
galy led  Oliver  and  others  to  use  extract 
of  the  healthy  suprarenal  capsules  in  the 
treatment  of  Addison's  disease,  and  with 
so  much  benefit  that  in  the  second 
edition  of  his  work,  in  1895,  Osier  had 
modiiied  his  previous  declaration  by 
saying:  "The  disease  is  usually  fatal. 
.  .  .  In  rare  instances  recovery  has 
taken  place,  and  periods  of  improvement, 
lasting  many  months,  may  occur." 

Case  of  recovery  in  a  man  of  57  years 
who,   in   April,   1885,   was   suddenly   at- 
tacked by  weakness,  ansemia,  pigmenta- 
tion of  the  mucous  membranes,  bronzed 
skin,  and,  a  little  later,  pain  in  the  re- 
gion of  the  capsules.     Strength  returned., 
little   by   little;     so   that   in  September, 
1886,  he  was  able  to  pass  half  an  hour 
out  of  bed.     At  the  same  time  the  pig- 
mentation grew  less  marked  and  grad- 
ually disappeared.     At  the  end  of  two 
years  the  patient  could  be  regarded  as 
cured,  and  recovery  has  since  been  main- 
tained.     H.    Neumann    (Deutsche    med. 
Woch.,  Feb.  1,  '94). 
As  the  disease,  in  a  large  majority  of' 
the  cases,  has  been  shown  to  be  tuber- 
culous, there  is  no  reason  why  some  cases 
may  not  recover,  as  well  as  in  some  cases 
of  tuberculosis   of  the  lungs  or  other - 
structiires.     A  very  guarded  prognosis, 
however,  is  most  judicious  in  all  cases 
of  this  disease. 

Treatment. — The  tendency  of  medical 
investigators,  in  the  last  two  or  three  ■ 


144 


ADDISON'S  DISEASE.    TREATMENT. 


decades,  has  been  to  seek  for  some  one 
specific  cause  for  each  disease  and  for 
each  a  specific  remedy.  This  has  caused 
the  careful  consideration  of  the  infl.uence 
of  predisposing  causes  to  be  more  neg- 
lected; less  attention  to  be  given  to  the 
influence  of  co-operative  causes,  espe- 
cially in  the  production  and  maintenance 
of  chronic  diseases;  and  less  appreciation 
of  the  effects  of  retained  excretory  prod- 
ucts during  the  progress  of  diseases,  both 
acute  and  chronic,  and  of  consequent 
changes  in  therapeutic  indications  in  dif- 
ferent stages  of  progress.  In  accordance 
with  these  tendencies  most  recent  writers 
have  devoted  but  few  words  to  the  con- 
sideration of  the  treatment  of  Addison's 
disease.  Not  being  able  to  identify  the 
specific  or  essential  cause,  we  are  assured 
that  no  specific  remedy  has  been  found, 
and  that  the  treatment  must  be  hygienic 
and  palliative:  i.e.,  we  must  endeavor 
to  improve  nutrition  by  suitable  diet, 
and  to  mitigate  the  more  important 
symptoms  as  they  arise.  The  truth  is, 
however,  that  very  few  chronic  diseases 
arise  from,  or  are  perpetuated  by,  a  single 
specific  cause.  Contrarily,  most  of  them 
are  readily  traceable  to  the  co-operation 
of  several  causes,  some  of  which  are 
called  predisposing  and  others  exciting 
factors.  And  even  in  the  few  chronic  dis- 
eases that  have  been  traced  etiologically 
to  a  specific  exciting  cause  or  pathogenic 
germ,  as  tuberculosis  of  the  lungs,  it  is 
generally  admitted  that  the  specific  germ 
alone  rarely  proves  efficient  in  developing 
the  disease  without  the  aid  of  such  pre- 
disposing factors  or  conditions  as  had 
diminished  the  natural  vital  resistance  of 
the  system  or  of  the  organ  attacked. 

In  the  treatment  of  all  such  cases, 
therefore,  it  is  very  important  that  we 
investigate  carefully  the  history  of  each 
patient  that  we  may  appreciate  whatever 
predisposing  influences  had  been  opera- 


tive, and  execute  such  measures  as  will 
prevent  their  further  influence.  In  the 
early  stage  of  Addison's  disease  the  pa- 
tient should  be  relieved  as  much  as  pos- 
sible from  both  hard  physical  labor  and 
mental  anxiety,  and  given  free  access  to 
pure  air  of  genial  temperature  and  a  fair 
variety  of  digestible  food. 

As  the  autopsies  reported  have  shown 
the  presence  of  tubercular  degeneration, 
not  only  in  the  suprarenal  capsule,  but 
also  in  other  structures  in  a  majority  of 
the  cases,  patients  should  be  encouraged 
to  go  early  to  mild  and  dry  climates  at 
moderate  elevations,  and  to  take  persist- 
ently such  remedies  as  have  been  most 
beneficial  in  the  more  common  forms  of 
tuberculosis.  Of  these,  perhaps,  for  pro- 
tracted use  none  are  better  than  creasote, 
in  some  form,  and  nuclein,  as  they  are 
both  antiseptic  and  tonic  to  the  digestive 
and  assimilative  organs.  If  the  creasote 
is  given  in  capsules,  V30  grain  of  strych- 
nine, added  to  each  dose,  will  aid  in  sus- 
taining the  fimctions  of  the  cardiac  and 
vasomotor  nervous  systems.  Arsenic  has 
been  strongly  recommended  in  such  cases 
as  will  tolerate  it  in  large  doses  without 
disturbing  the  stomach  and  intestines. 
In  one  case  under  my  care  the  patient 
appeared  to  derive  much  benefit  from 
potassio-tartrate  of  iron,  given  in  mod- 
erate doses  in  connection  with  digitalis. 
In  the  later  stage  of  the  disease,  when 
the  asthenia  is  profound,  the  patient 
should  be  kept  much  in  the  recumbent 
position,  and  his  gastric  and  intestinal 
disturbances  combated  by  the  use  of  bis- 
muth subnitrate,  cerium  oxalate,  and 
sometimes  creasote  with  codeine. 

Since  it  has  been  ascertained  by  very 
careful  experiments  that  the  healthy 
suprarenal  capsules  contain  an  active 
substance  capable  of  producing  a  decided 
stimulant  and  tonic  effect  on  the  cardiac 
and   other   ganglia    of  the   sympathetic 


ADDISON'S  DISEASE.     TREATMENT. 


145 


nervous  system,  and  of  efficiently  in- 
creasing the  vasomotor  functions  with 
slow  heart-beat  and  greater  blood-press- 
ure, their  use  in  the  treatment  of  Ad- 
dison's disease  has  been  tested,  more  or 
less,  by  almost  every  physician  having  a 
case  under  his  care.  Oliver,  who  has 
been  most  active  in  investigating  the 
action  of  preparations  of  the  suprarenal 
capsules  and  their  value  in  the  treatment 
of  Addison's  disease,  says  they  may  be 
used  in  the  form  of  alcoholic  tincture 
and  of  either  fluid  or  dry  extract.  The 
best  mode  of  administration  is  by  the 
mouth,  and  of  the  dry  extract  in  the 
form  of  tablets  of  2  V2  grains  each,  one 
of  which  may  be  taken  three  times  a  day, 
and  slowly  increased  to  five  or  six  in  the 
twenty-four  hours. 

Extract  or  tincture  of  suprarenal  cap- 
sules tried  in  several  cases.  Good  results 
obtained  not  only  as  a  means  of  restor- 
ing muscular  strength  and  improving 
the  general  condition,  but  sometimes  as 
a  true  curative  remedy.  Maragliano 
(Eiforma  Med.,  Dee.  4,  '94) ;  Shoemaker 
(Univ.  Med.  Mag.,  Feb.,  '95)  ;  Lloyd 
Jones  (Brit.  Med.  Jour.,  Aug.  24,  '95)  ; 
Oliver  (Brit.  Med.  Jour.,  Aug.  31,  '95). 
Case  of  a  man,  aged  44  years,  some- 
what addicted  to  alcoholic  excesses  and 
subject  to  occasional  attacks  of  asthma, 
who,  during  the  months  of  February, 
March,  and  April,  developed  all  the  char- 
acteristic symptoms  of  severe  Addison's 
disease.  During  the  month  of  May  he 
received  a  subcutaneous  injection  of 
suprarenal  capsular  juice,  1  cubic  centi- 
metre every  two  days.  During  one 
month  of  this  treatment  his  appetite  and 
strength  had  returned  and  he  had  gained 
four  kilogrammes  in  weight.  On  the 
14th  of  June  he  had  a  violent  quarrel 
with  a  neighbor,  and  all  his  former  bad 
symptoms  began  to  return,  and  caused 
his  death  on  the  14th  of  July.  No 
autopsy  was  made.  Spillmann  (Rev. 
Med.  de  I'Est.,  Jan.  15,  '96). 

Case  of  a  man,  46  years  of  age,  suffer- 
ing from  pulmonary  tuberculosis  and 
Addison's  disease  with  marked  pigmen 

1—10 


tation  of  the  skin  and  of  the  mucous 
membrane  of  the  palate,  treated  with  an 
extract  prepared  from  the  fresh  suprar- 
enal glands  of  the  pig  extracted  and 
preserved  in  glycerin.  One  drachm  of 
the  extract  corresponded  to  one  suprar- 
enal gland,  and  the  patient  at  first  was 
given  V=  drachm  three  times  a  day. 
This  treatment  was  continued  for  eight 
months,  and  the  patient  was  discharged 
in  a  greatly  improved  state,  having 
gained  in  weight  and  strength  and  the 
pulse-frequency  being  much  lessened. 
Four  months  later  the  patient  was  still 
in  good  health.  William  Osier  (Inter. 
Med.  Mag.,  Feb.,  '96). 

Case  in  which  the  symptoms  were  typ- 
ical and  characteristic  of  Addison's  dis- 
ease. Very  great  improvement  resulted 
from  the  administration  of  suprarenal 
extract.  On  careful  examination  after 
death  both  suprarenal  capsules  were  ab- 
sent, the  right  being  entirely,  and  the 
left  almost  entirely,  replaced  by  fat. 
Byrom  Brarawell  (Brit.  Med.  Jour.,  Jan. 
9,   '97). 

Forty-eight  cases  of  Addison's  disease 
from  literature,  which  were  treated  with 
adrenal  gland.  Of  these,  6  seemed  cured, 
22  were  improved,  18  unimproved,  and  2 
became  worse.  In  many  of  the  eases 
there  was  such  a  grave  tuberculosis  of 
other  organs  as  to  preclude  expectation 
of  marked  improvement.  F.  P.  Kinni- 
eutt   (Amer.  Jour.  Med.  Sci.,  July,  '97). 

Man  of  49,  with  well-marked  Addison's 
disease,  treated  with  tablets  of  suprar- 
enal gland,  beginning  with  10  grains 
daily  and  increasing  up  to  200  grains. 
At  the  end  of  the  year  the  man  was  en- 
tirely well.  C.  W.  Suckling  (Brit.  Med. 
Jour.,  May  28,  '98). 

Case  of  Addison's  disease  in  all  respects 
very  typical,  and  in  addition  a  small 
phthisical  lesion  at  apex  of  one  lung.  He 
was  given  daily  3  "/^  to  12  V2  drachms  of 
fresh  suprarenal  glands  of  beef,  veal,  or 
mutton,  and  also  during  some  part  of  the 
time  hypodermic  injections  of  solution  of 
suprarenals  in  glycerin  and  water.  For 
five  months  there  was  no  obvious  im- 
provement. After  further  lapse  of  time 
strength  began  gradually  to  return  and 
pigmentation  to  diminish  in  intensity,  so 


146 


ADDISON'S  DISEASE.    TREATIIENT. 


that  finally  he  was  able  to  resume  his 
employment,  and  was  still  at  work  three 
years  later.  Beclere  (Semaine  Med., 
Mar.  2.  '98). 

Case  of  Addison's  disease  treated  with 
the  fresh  suprarenal  gland,  with  distinct 
improvement  of  general  health,  but  pig- 
mentation remained  unchanged,  and  pa- 
tient died  two  years  later.  Hayem  (Sem. 
Med.,  Mar.  2,  '98). 

Case  of  Addison's  disease  in  a  man 
aged  54  years.  The  symptoms  of  the 
disease  were  marked.  One-twelfth  grain 
of  the  extract  of  suprarenal  glands  of 
sheep  was  given  three  times  daily. 
Treatment  has  been  continued  for  two 
years  at  intervals.  Asthenia,  nausea, 
faintness,  and  pigmentation  have  almost 
entirely  disappeared.  Twice,  when  the 
extract  could  not  be  obtained  for  ten 
days,  attacks  of  severe  faintness,  clammy 
sweats,  and  muscular  twitchings,  with 
fever  and  bounding  pulse,  resulted;  they 
were  relieved  on  the  exhibition  of  the 
drug.  R.  A.  Bate  (Amer.  Pract.  and 
News,  vol.  xxviii,  p.  90,  '99). 

Suprarenal  extract  should  be  tried  in 
all  cases.     There  is  little  hope  in  cases 
of  tuberculous  origin;   in  those  due  to 
atrophy,      sclerotic      or      inflammatory 
changes;  but,  if  a  portion  of  the  gland 
is  still  active,  the  extract  will  probably 
be   found   beneficial.     J.   V.   Shoemaker 
(Jour.    Amer.    Med.    Assoc,    Mar.    23, 
1901). 
Grainger  Stewart,   MeCall  Anderson, 
and  other  observers  have  reported  cases 
treated  with  the  suprarenal  extract  with- 
out benefit. 

Case  of  Addison's  disease  treated  with 
suprarenal  extract.  Much  improvement 
took  place  during  the  first  four  weeks, 
after  which  the  failure  was  rapid  until 
death  occurred.  Reference  to  9  other 
cases  recorded  in  which  improvement  had 
taken  place  in  5,  in  2  no  improvement, 
1  died  early,  and  1  continued  treatment 
but  a  few  days.  Sydney  Ringer  and  A. 
Phear  (Brit.  Med.  Jour.,  Jan.  18,  '96). 

Typical  ease  in  which  the  patient  had 
been  taking  suprarenal  capsule  by  the 
mouth  for  some  time.  The  only  appar- 
ent effect  was  that  the  temperature, 
which  had  been  subnormal,  had  returned 


to    normal.      T.    E.    Bradshaw    (Lancet, 
Oct.  31,  '96). 

Administration  of  suprarenal  extract 
in  case  of  Addison's  disease  caused  a  dis- 
turbance of  nitrogen-equilibrium,  leading 
to  increased  consumption  of  body-albu- 
mins and  to  loss  of  weight.  Max  Pick- 
ardt  (Berliner  klin.  Wocli.,  Aug.  15,  '98). 
Suprarenal  capsules  administered  sub- 
cutaneously  to  a  ease  of  Addison's  dis- 
ease; within  twenty-four  hours  patient 
died  with  subnormal  temperature  and 
great  prostration  and  collapse.  P.  Cour- 
mont  (Quatrieme  Congres  Frang.  de 
Med.  Int.,  '98). 

Series  of  43  cases  of  the  disease  col- 
lected treated  with  suprarenal  extract; 
of  these,  13  were  improved,  9  recovered, 
11  died,  3  showed  no  improvement,  and 
the  result  was  not  recorded  in  7.  W.  W. 
Johnston  (Amer.  Med.  Congress;  Brit. 
Med.  Jour.,  June  2,  1900). 

Case  of  Addison's  disease  in  a  man  of 
40  in  which  suprarenal  extract  was  given 
twice  daily  without  effect,  though  it  was 
not  used  till  late  in  the  course  of  the  dis- 
ease.   Necropsy  showed  capsulated  tuber- 
culous   deposits    in    the    spinal    column, 
lungs,  and  bronchial  glands.     The  sub- 
stance of  both  suprarenal  bodies  was  re- 
placed almost  entirely  by  fibrous  tissue. 
E.  G.  Trevithick  (Lancet,  July  14,  1900). 
Report  of  8  cases,  in  6  of  which  an 
attempt  was  made  to  treat  the  disease 
with   suprarenal   preparations.     The  re- 
sults obtained  so  far  have  been  disap- 
pointing, but  do  not  warrant  the  giving 
up  of  all  hope  of  some  degree  of  ulti- 
mate success.    Most  of  the  patients  suf- 
fering from  this  disease  are  already  in 
the   last   stages   when   the   diagnosis   is 
made.     C.   R.   Box    (Practitioner,   May, 
1901). 
Contradictory  results  having  been  ob- 
tained   ever   since    preparations    of    the 
suprarenal  capsules  were  first  used  in  the 
treatment  of  eases  of  Addison's  disease, 
it  is   impossible  to   determine   the   real 
value   of  this  treatment,  it  being  well 
known  that  a  considerable  proportion  of 
the  eases  continue  a  number  of  years, 
though  they  often  show  periods  of  im- 
provement.    And  for  the  same  reason  it 


ADDISON'S  DISEASE. 


147 


is  not  possible  to  determine  whether  the 
cases  reported  as  cured  will  prove  perma- 
nent or  only  temporarj'.  Moreover,  if 
the  clinical  symptoms  and  conditions 
constituting  Addison's  disease  result 
from  the  interruption  of  the  functions  of 
the  suprarenal  capsules,  there  must  have 
been  a  prior  pathological  condition  caus- 
ing such  interruption.  And,  while  we 
might  reasonably  expect  the  use  of  su- 
prarenal extract  to  relieve  the  pigmenta- 
tion and  asthenia  so  long  as  its  iise  was 
continued,  unless  it  also  removed  this 
primary  pathological  condition,  the  as- 
thenia and  pigmentation  would  sooner  or 
later  return,  certainly  after  the  discon- 
tinuance of  the  remedy.  The  whole  sub- 
ject needs  more  careful  and  protracted 
investigation. 

Eemoval  of  the  diseased  adrenal  by 
surgical  procedures  is  one  of  the  latest 
means  employed, — accidentally,  it  may 
be  said,  for  the  operation  in  the  case 
reported  had  been  performed  for  the 
removal  of  a  malignant  retroperitoneal 
growth  that  turned  out  to  be  a  tuber- 
culous suprarenal  capsule. 

Case  of  recovery  after  removal  of  a 
tuberculous  adrenal  lying  directly  on  the 
spinal  column  and  appearing  as  a  small,, 
movable,  firm,  nodular  tumor.  Pressure 
over  it  brought  on  a  characteristic  at- 
tack of  pain.  The  patient  recovered  in 
ttt'o  weeks.  All  the  symptoms  disap- 
peared after  the  operation.  Eight 
months  later  no  evidence  of  the  disease 
could  be  discovered.  Oestreich  (Zeit.  f. 
klin.  Med.,  B.  31,  p.  123,  '97). 

Nathan  S.  Davis, 

Chicago. 

ADENITIS.— Gr.,  ahriv.&  gland;  itis, 
inflammation. 

Definition. — Inflammation  of  a  gland. 

Varieties. — Adenitis  may  be  acute,  due 
almost  invariably  to  infection  from  an 
attack  of  angioleueitis  and  occasionally 
to  injury  or  strains;  or  chronic,  resulting 


from  either  of  the  preceding,  especially 
in  strumous  or  cachectic  persons,  and 
from  slight  sources  of  irritation,  and  not 
uncommonly  resulting  in  permanent  en- 
largement and  induration  or  in  tuber- 
culous degeneration.  Adenitis  of  spe- 
cific origin  will  be  described  under 
Syphilis  and  Ueinahy  System. 

Acute  Adenitis. 

Symptoms.  —  The  general  symptoms 
depend  upon  the  extent  and  severity  of 
the  infection.  Eigors  may  occur  when 
pus  forms.  The  temperature  is  fre- 
quently elevated.  If  the  infection  is 
severe,  symptoms  of  profound  septiese- 
mia  appear. 

The  local  symptoms  are,  by  far,  the 
most  prominent  in  the  majority  of  cases, 
and  consist  of  pain,  heat,  and  swelling. 
The  suffering  varies  from  a  slight  sore- 
ness only  to  intense  pain,  according  to 
the  position  of  the  gland,  its  relations 
with  the  surrounding  tissues,  and  the 
density  of  the  tissue  in  which  it  is  im- 
bedded. The  heat  may  vary  according 
to  the  degree  of  the  congestion  present. 
The  swelling  may  either  be  great  or 
slight.  If  the  lesion  be  confined  to  the 
gland,  it  will  be  well  defined;  if  peri- 
adenitis is  present,  the  swelling  will  be 
more  or  less  diffuse.  Glands  in  any  re- 
gion of  the  body  may  be  affected,  but 
those  of  the  neck,  axilla,  and  groin  more 
than  the  others;  this  is  due  to  the  fact 
that  infection  generally  enters  the  sys- 
tem through  the  mouth,  throat,  genital 
organs,  and  the  extremities. 

In  the  congestive,  or  exudative,  stage, 
pain  and  swelling  are  present  in  the 
region  of  the  glands;  if  the  glands  are 
superficial  the  swelling  is  ovoid  with  the 
long  axis  coinciding  with  the  direction 
of  the  afferent  lymphatics,  and  palpation 
reveals  several  movable,  hard,  elastic,  and 
tender  rounded  masses. 

When  the  glands  are  deep,  as  in  the 


148 


ADENITIS.     A.CUTE.    DIAGNOSIS.    ETIOLOGY. 


axilla,  abdomen,  or  even  the  neck,  the 
results  of  palpation  are  less  definite  and 
satisfactory. 

In  the  siTppurative  stage  the  pain  in- 
creases and  becomes  sharp  and  catching, 
the  skin  reddens,  and  the  periglandular 
tissue  swells. 

If  the  gland  alone  suppurates  the  skin 
remains  normal,  while  under  it  may  be 
felt  the  softened  and  enlarged  gland. 
This  latter  opens  outwardly  or  into  the 
neighboring  cellular  tissue  on  from  the 
sixth  to  the  fifteenth  day  of  the  affection. 
When  the  gland  opens  outwardly,  the 
cicatrix  is  much  smaller  than  when  it 
ruptures  into  the  celMar  tissue,  as  in  the 
latter  case  it  gives  rise  to  an  abscess. 

If  the  cellular  tissue  around  the  gland 
suppurates  the  skin  becomes  hot,  swollen, 
and  painful,  and  fluctuation  may  be  felt. 
Two  foci  of  suppuration  are  thiis  estab- 
lished. .  The  skin  is  occasionally  under- 
mined by  the  pus.  Eecovery  is  possible, 
however,  without  suppuration  of  the 
gland. 

Both  the  gland  and  the  cellular  tissue 
around  it  may  suppurate,  either  simul- 
taneously, or  suppuration  of  the  cellular 
tissue  may  precede  that  of  the  glands, 
•or  the  latter  may  suppurate  and  rupture 
into  the  surrounding  cellular  tissue  and 
itoim  an  abscess.  Pus  is  usually  pro- 
duced in  considerable  quantity,  and  the 
affection  is  of  long  duration. 

Suppurative  adenitis  may  result  in 
•cicatrization  after  several  weeks.  This 
cicatrix  may  reopen  to  allow  the  exit  of 
pus  from  a  suppurated  gland.  On  the 
other  hand,  a  fistula  may  result,  which 
may  give  exit  to  sero-pus  or  to  lymph 
(Despres).  A  lymphatic  gland  or  vessel 
will  then  be  found  at  the  bottom  of 
the  abscess-cavity,  below  the  crater-like 
■opening. 

As  the  suppuration  usually  starts  in 
more  than  one  focus  in  the  gland,  the 


first  sensation  to  the  touch  will  be  one 
of  bogginess,  which  periglandular  con- 
gestion may  render  obscure.  "Well- 
defined  fluctuation  is  found  only  when 
considerable  tissue  is  destroyed. 

Diagnosis. — The  diagnosis  of  ordinary 
superficial  acute  adenitis  is  usually  easy; 
it  is  more  difficult  when  the  neighboring 
cellular  tissue  is  also  inflamed;  it  may 
be  impossible  in  cases  of  deep-seated  or 
visceral  adenitis. 

In  adenitis  of  the  inguino-crural  re- 
gion the  swelling  is  found  in  the  external 
portion  of  the  region  if  due  to  a  lesion 
of  the  gluteal  tissues,  and  in  the  inner 
portion  of  the  region  if  due  to  a  lesion 
of  the  anus,  perineum,  or  external  geni- 
tals. In  both  conditions  the  tumor  will 
have  its  long  axis  directed  more  or  less 
horizontally. 

The  swelling  will  be  found  in  the 
lower  portion  of  the  inguino-crural  re- 
gion, with  the  long  axis  directed  more 
or  less  vertically,  if  the  lesion  causing  it 
is  situated  on  the  foot,  leg,  or  lower  part 
of  the  thigh.  This  disposition  is  due 
to  the  anatomical  relations  of  the  lym- 
phatic vessels  and  glands,  and  should  be 
borne  in  mind.  Operation  for  strangu- 
lated crural  (femoral)  hernia  has  been 
performed  for  an  adenophlegmon  of  the 
crural  canal. 

Etiology. — The  lymphatic  glands  serve 
as  reservoirs  on  the  course  of  the  lym- 
phatic vessels,  through  which  any  irri- 
tants or  infection  must  pass. 

Cold  and  overexertion  act  as  local 
depressants,  and  thus  may  indirectly 
favor  the  development  of  adenitis.  Gen- 
eral debility  has  the  same  effect.  The 
following  varieties  of  adenitis,  etiolog- 
ically  regarded,  are  recognized: — 

1.  Adenitis  by  contiguity,  resulting 
from  the  propagation,  by  contact,  of  a 
neisfhboring  inflammation. 


ADENITIS.  ACUTE.  PATHOLOGY. 


149 


Three  cases  of  suppurating  inguinal 
glands  accompanying  gonorrhoea  in 
which  a  bacteriological  examination  of 
the  pus  showed  the  presence  of  gono- 
eocci.  Pure  culture  of  typical  gonococci 
obtained  in  one  case;  on  being  placed 
in  the  urethra  of  a  healthy  man  this  set 
up  a  characteristic  gonorrhoea.  In  the 
two  other  cases,  in  which  the  abscesses 
opened  spontaneously,  examination  of 
the  pus  from  the  fistulous  tract  showed 
the  presence  of  gonococci  and  strepto- 
.  cocci.  An  attempt  to  cultivate  the  cocci 
on  Wertheim's  medium,  made  in  one  of 
these  cases,  failed.  Hansteen  (Arehiv  f. 
Derm,  und  Syph.,  vol.  xxxviii).  (See 
Ukethea.) 

2.  Adenitis  by  continuity  or  following 
lymphangitis. 

3.  Adenitis  by  embolism,  due  to  the 
transportation  of  septic  or  irritating 
matter,  produced  in  the  system  or  com- 
ing from  the  outside. 

Adenitis  of  the  mesenteric  glands  may 
be  due  to  dysentery  or  to  the  inflamma- 
tion of  Peyer's  patches  in  typhoid  fever. 

Adenitis  occurs  in  carbuncle,  furuncle, 
vaccination,  erysipelas,  and  eruptive  or 
infectious  fevers. 

Pathology. — If  suppuration  does  not 
occur,  resolution  may  take  place,  or 
chronic  enlargement  of  the  gland  may 
follow  hyperplasia  of  the  connective- 
tissue  stroma  of  the  gland. 

If  suppuration  does  occur  the  sur- 
rounding connective  tissue  may,  and 
usually  does,  suppurate;  then  the  more 
or  less  disintegrated  gland  lies  in  a  sitp- 
purating  cavity  formed  by  the  circum- 
jacent connective  tissue. 

There  are  two  forms  of  acute  adenitis 
depending  upon  the  degree  of  inflamma- 
tion present: — 

1.  Exudative  adenitis.  In  this  form 
the  gland  is  swollen,  and  it  feels  hard 
and  elastic.  On  section  it  appears  red- 
dish brown,  like  the  spleen,  with  small 
foci  of  hffimorrhage,  all  of  which  indicate 
excessive    dilatation    of   the    capillaries. 


The  lymphatic  stream  is  arrested  by  the 
dilatation  of  the  cortical  lymph-sinuses 
and  their  obstruction  by  fibrin,  granular 
material,  and  portions  of  altered  white 
corpuscles.  The  Ij'mph-f  ollicles  are  filled 
with  fibrin  and  accumulated  lymph-cells. 
The  stroma  of  the  gland  is  swollen  and 
infiltrated  with  cells. 

If  the  section  of  the  gland  is  scraped, 
a  milky  liquid  will  be  obtained,  which 
contains  white  corpuscles  and  epithelial 
cells,  the  latter  showing  several  nuclei. 

2.  Suppurative  adenitis.  In  this  va- 
riety the  gland  softens,  its  tissues  become 
more  brittle,  hsemorrhagic  infiltration 
centres  form  that  soon  change  into  yel- 
low, purulent  foci.  These,  at  first  dis- 
tinctly separate,  soon  unite,  forming  an 
abscess  within  the  fibrous  capsule  of  the 
gland.  Sometimes  the  periglandular 
tissue  suppurates,  while  the  gland  does 
not. 

The  glandular  abscess  and  the  peri- 
glandular abscess  may  open  externally, 
each  one  separately  or  both  simulta- 
neously. The  suppurating  gland  may 
rupture  into  the  cellular  tissue.  Occa- 
sionally the  gland  is  hard  and  elastic;  it 
may  be  difficult  to  separate  it  from  its 
fibrous  capsule.  The  afferent  Ijinphatics 
are  enlarged  and  thickened.  The  lymph- 
cells  and  cortical  follicles  are  few  in 
number  and  have  undergone  granulo- 
fatty  degeneration. 

Seven  cases  of  articular  rheumatism 
in  which  the  lymphatic  glands  situated 
above  the  affected  joints  were  swollen 
and  painful,  the  pain  or  tenderness  in- 
creasing with  that  of  the  joint-affection. 
During  the  attacks  some  were  of  the 
size  of  a  nut  and  rolled  under  the  finger. 
No  periadenitis  or  diffuse  swelling  was 
present. 

In  almost  every  case  some  previous  in- 
fectious disease  was  to  be  found  with 
which  the  chronic  rheumatism  could  be 
connected.  Bacteriological  examinations, 
however,    carried    out    either    with    the 


150 


ADENITIS.     ACUTE.     PROGNOSIS.     TREATMENT. 


intra-articular     liquid     withdrawn     by- 
aspiration    or    by    fragments    of   glands 
removed  aseptically,  gave  almost  no  re- 
sults.     A.    Chauffard    and    F.    Ramond 
(Rev.  de  Med.,  May  10,  '96). 
Prognosis.  —  The  prognosis  is  usually 
favorable;    it  may  be  unfavorable,  how- 
ever, when  extensive  abscesses  form  in 
the  neighborhood  of  important  organs. 

Deep-seated  suppurative  adenitis  may 
give  rise  to  dangerous  complications, 
especially  in  certain  regions,  like  the 
neck  and  mediastinum,  on  account  of  the 
purulent  extensions  (through  burrowing) 
and  the  difficulty  of  evacuating  the  pus. 
Ulceration  of  the  great  vessels  of  the 
neck  giving  rise  to  grave  haemorrhages 
may  also  occur. 

Case,  in  the  practice  of  Johnston,  in 
which  the  internal  jugular  vein  was 
ligated  for  profuse  hseniorrhage,  caused 
by  a  sloughing  adenitis  following  malig- 
nant scarlet  fever.  L.  H.  Adler,  Jr. 
(Univ.  Med.  Mag.,  Dec,  '91). 

Treatment.  —  The  first  indication  in 
acute  adenitis  is  to  remove  any  source 
of  irritation  or  infection.  Any  wound, 
abrasion,  opening,  or  any  natural  cavity 
with  which  either  of  these  may  connect 
should  be  so  treated  as  to  bring  about 
absolute  local  asepsis. 

If  the  case  is  seen  early  enough,  cold 
applications  should  be  made  to  the  af- 
fected region.  Cold  inhibits  the  multi- 
plication of  bacteria,  but  when  applied 
late  it  favors  the  death  of  cells,  and 
should  consequently  be  avoided. 

The  region  in  which  the  affected  gland 
is  situated  should  be  kept  at  rest  and,  if 
possible,  elevated.  In  this  manner  the 
afl'erent  arterial  current  is  diminished, 
while  the  efferent  venous  and  lymphatic 
currents  are  increased. 

To  prevent  suppuration  gray  mercurial 
ointment,  very  gently  rubbed  in,  is  use- 
ful. The  injections  of  from  5  to  10 
minims    of    a    3-per-cent.    carbolic-acid 


solution   into    an   inflamed    gland    have 
also  proven  satisfactory. 

Case  in  which  injections  of  carbolic 
acid  destroyed  the  tendency  of  the 
glands  to  develop.  Schwartz  (Revue 
Gen.  de  Clin,  et  de  Ther.,  Mar.  4,  '91). 

In  cervical  adenitis  it  is  necessary  be- 
fore the  skin  is  altered  to  treat  abscess 
by  punctures  with  a  fine  needle  and 
modifying  injections.  If  this  method 
adopted,  cure  without  cicatrix  in  99  per 
cent,  of  cases.  When  \\'ith  general  treat- 
ment and  stay  of  six  months  or  more  at 
sea-side,  gland  remains  swelled  and  in- 
durated, neither  showing  signs  of  reso- 
lution nor  advancing  toward  softening, 
injections  of  l-in-50  chloride-of-zinc 
solution  gives  best  results.  Injection  re- 
peated three  or  four  times,  at  two  days' 
intervals,  with  30  to  60  drops  of  this 
solution.  This  nearly  always  leads  to 
commencement  of  softening,  which  is 
finished  by  injections  of  camphorated 
naphthol.  Calot  (Presse  Med.,  Oct.  22, 
'98). 

If  it  is  desired  to  hasten  sitppuration, 
warm  antiseptic  fomentations  are  to  be 
used  in  preference  to  poultices.  The 
compound  resin  cerate  of  the  pharma- 
copoeia is  efEective  for  this  purpose,  and 
is  antiseptic  as  well. 

When  pus  has  formed  the  gland  should 
be  opened  by  a  generous  incision,  sinuses, 
if  present,  being  opened  throughout  their 
entire  length  to  facilitate  treatment. 
The  contents  are  then  carefully  removed, 
and  the  infiltrated  wall  scraped  with  a 
sharp  curette.  The  cavity  should  then 
be  packed  with  iodoform  gauze,  or  gauze 
impregnated  with  camphorated  naphthol 
or  salol.  The  dressing  may  be  removed 
on  the  third  day. 

In  the  treatment  of  cases  of  simple 
chronic  adenitis,  applications  of  iodine, 
compression,  and  local  blistering  have 
given  the  best  results. 

Blisters,  nitrate  of  silver,  or  iodine 
tincture  should  be  applied  around,  but 
not  over,  the  inflamed  gland. 


ADENITIS.    CHRONIC.     SYMPTOMS. 


151 


In  adenitis  complicating  articular 
rlieumatism  the  beat  results  are  obtained 
from  the  tincture  of  iodine  given  in- 
ternally; 100  drops  in  divided  doses  are 
given  daily;  long  continued  use  is  ad- 
vised. A.  Chauffard  and  F.  Ramond 
(Rev.  de  Med.,  May  10,  '96). 

Excision  may  be  performed  if  the  mass 
be  large  or  disfiguring. 

1.  Whenever  fluid — that  is,  pus — can 
be  detected  in  connection  with  a  dis- 
eased lymphatic  gland,  the  operation 
should  be  done  before  the  skin  becomes 
red  and  thin.  2.  When  the  diseased 
gland  is  subcutaneous — that  is,  not  be- 
neath the  deep  fascia  or  muscle,  and 
has  been  completely  removed — the  least 
scar  will  result  if  neither  stitches  nor 
drainage-tube  be  used,  especially  if  it  be 
possible  to  leave  the  wound  uncovered 
by  dressing  and  exposed  to  the  air,  so 
that  the  edges  may  be  drawn  and  glued 
together  by  drying  lymph.  3.  If  the 
diseased  gland  be  beneath  the  muscle  or 
muscular  fascia,  then  a  drainage-tube 
must  be  used  and  the  edges  of  the  wound 
must  be  united  by  suture.  The  best 
drainage-tube  is  the  gilt  spiral  wire, 
especially  as  it  ihay  have  to  remain 
from  two  to  eight  or  ten  weeks,  accord- 
ing to  the  depth  of  the  wound  or  the 
completeness  of  the  removal  of  the  gland. 
4.  Where  many  glands  have  to  be  re- 
moved, it  is  better  to  remove  them 
through  a  series  of  small  incisions  and 
thereby  avoid  very  extensive  ones.  All 
sinuses  and  suppurating  cavities  should 
be  thoroughly  cleansed  by  means  of 
scraper  and  lint,  so  as  to  leave  a  fresh 
surface  free  from  granulation  or  decayed 
or  decaying  tissue,  and  that  a  drainage- 
exit  should  be  maintained  until  all  the 
deep  parts  are  healed.  Teale  (Brit.  Med. 
Jour.,  No.   1717,  '93). 

Important  to  avoid  tearing  or  wound- 
ing the  gland  in  removing  it,  to  keep 
close  to  its  surface  in  order  to  prevent 
haemorrhage,  and  to  use  transverse  in- 
cisions. W.  K.  Treves  (Brit.  Med.  Jour., 
No.  1717,  '93). 

Electricity,  preferably  the  constant 
current,  is  highly  recommended  by  some 
authors.     Daily  sittings  of  ten  minutes 


each,   using   5   to   15   milliampei'es,   are 

required. 

The  great  majority  of  the  cases  of 
cervical  adenitis  are  to  be  treated  medi- 
cally, since  they  only  come  under  ob- 
servation after  suppuration  has  oc- 
curred. In  the  cases  of  tubercular 
adenitis  which  are  not  yet  suppurating, 
extirpation  through  a  small  incision  is 
indicated  at  once,  with  medical  after- 
treatment  to  prevent  recurrence.  When 
one  hard,  caseous  nodiile  exists,  it 
should  at  once  be  extirpated,  unless  the 
resulting  scar  will  cause  marked  de- 
formity. When  these  are  multiple,  im- 
mediate extirpation  is  the  treatment  to 
be  followed.  Should  the  adenitis  be- 
come purulent,  extirpation  is  only  in- 
dicated after  all  other  methods  of  treat- 
ment have  failed.  Local  injections  are 
advised,  with  a  long  sojourn  at  the  sea- 
shore, especially  should  fistulae  occur. 
Clean  dressings  must  be  applied  to  the 
fistulae  to  prevent  secondary  infection. 
When  extirpation  is  done,  it  should  be 
complete.  A.  Broca  (Jour,  des  Prati- 
ciens,  Oct.  26,  1901). 

Codliver-oil,  the  iodides,  and  iron  are 
indicated  in  all  cases  when  the  digestive 
organs  do  not  rebel  against  their  use. 
Arsenic  and  strychnine  are  the  agents 
next  in  order,  and  sometimes  prove  very 
effective.  Out-of-door  life  and  plentiful 
nourishment  are  of  primary  importance. 

Chronic  Adenitis. 

Symptoms.  —  The  symptoms  vary  ac- 
cording to  the  period  of  development  in 
which  the  diseased  gland  is  found  at  the 
time  of  examination. 

Three  periods  of  development  are 
commonly  recognized  in  tuberculous 
adenitis:  the  period  of  induration,  or 
indolence;  the  period  of  inflammation; 
and  the  period  of  suppuration. 

1.  Period  of  Induration,  or  Indolence. 
— This  period  may  last  for  years,  and 
resolution  may  even  take  place,  though 
the  gland  always  remains  somewhat  en- 
larged and  indurated.  The  glands  are 
felt   as  hard,    elastic,    enlarged   bodies, 


153 


ADENITIS.     CHRONIC.     SYMPTOMS. 


rolling'  under  the  finger,  with  more  or 
less  distinctness  as  they  are  situated 
superficially  or  deep.  No  h€at,  pain,  or 
redness  of  the  skin  is  perceived. 

2.  Period  of  Inflammation.  —  In  this 
period  we  have  pain,  redness  of  the  skin, 
and  tenderness  on  pressure.  The  gland, 
if  solitary,  may  adhere  to  the  skin. 
Fluctuation  may  be  present. 

3.  Period  of  Suppuration.  ■ —  In  this 
period  we  notice  much  more  softening 
of  the  contents  of  the  gland  than  a  real 
suppuration.  The  skin  may  ulcerate 
through  almost  without  inflammatory 
symptoms,  and  the  contents — consisting 
of  caseous  matter  half-dissolved  in  a 
whitish  watery  fluid — may  be  evacuated. 
When  periadenitis  occurs,  true  pus  may 
be  present. 

If  chains  of  glands  are  tuberculous, 
the  latter  inflame  alternately  and  dis- 
charge their  contents  in  the  same  order, 
a  series  of  abscesses  being  thus  formed. 

When  the  contents  of  the  gland  are 
discharged,  the  skin  may  become  ulcer- 
ated in  the  neighborhood,  form  fistulje, 
and  a  depressed,  adherent,  violet  cicatrix 
finally  form. 

In  some  cases  a  fistula  may  form  and 
last  for  years;  the  skin  may  be  under- 
mined, and  disfiguring  cicatrices  may  be 
formed. 

Cretaceous  transformation  occurs  at 
times  in  the  deeper  glands,  but  rarely 
in  the  superficial  ones.  Some  caseous 
glands  undergo  a  process  which  trans- 
forms them  into  a  cyst-like  cavity  con- 
taining a  serous  liquid. 

Chronic  adenitis  may  assume  various 
forms. 

1.  General  Tuherculoiis  Adenitis.  — 
This  presents  itself  especially  in  negroes. 
Organs  other  than  the  glands  are  but 
little  affected,  and  continuous  fever 
exists.  The  retroperitoneal,  bronchial, 
and  mesenteric  glands  are  the  most  en- 


larged. It  resembles,  in  many  ways,  an 
acute  attack  of  Hodgkin's  disease. 

2.  Local  Tuberculous  Adenitis.  —  (a) 
Cervical.  This  form  is  usually  met  with 
in  children,  and  begins  in  the  submax- 
illary glands,  which  are  generally  more 
enlarged  on  one  side. 

(&)  Bronchial.  This  form  is  thought 
to  be  always  secondary  to  a  fociis  in  the 
lungs,  by  some  authors,  but  this  opinion 
is  contested  by  many  others.  Osier  among 
them.  Local  lung-infection,  pericardial 
infection,  and  general  infection  are  to  be 
feared,  however. 

(c)  Peribronchial.  In  this  form  we 
must  realize  the  importance  of  lesions 
resulting  from  caseation.  There  is  a 
softening  of  the  lymphatic  glands  situ- 
ated aroimd  the  lower  end  of  the  trachea 
and  main  bronchi.  Evidence  from  per- 
cussion is  of  doubtful  value;  alterations 
in  breath-sounds  are  much  more  impor- 
tant, especially  when  unilateral;  divided 
respiration,  with  prolonged  expiration, 
is  found  vmaccompanied  by  any  adven- 
titious sounds.  In  cases  in  which  the 
enlarged  glands  ulcerate  through  the  air- 
tubes,  the  breath  has  a  very  offensive 
odor,  and  co-existence  of  fcetor  with 
haemoptysis  and  evidence  of  pulmonary 
consolidation  are  suggestive.  When 
vomiting  of  blood  and  its  passage  by  the 
bowel  is  added,  the  diagnosis  of  glands 
rupturing  into  bronchus  and  oesophagus 
is  the  most  likely  one.  The  annexed 
colored  plate  distinctly  shows  the  ana- 
tomical relations  of  the  peribronchial 
glands. 

{d)  Mesenteric.  This  form  may  be 
primary,  and  is  thus  very  common  in 
children,  or  secondary  to  local  intestinal 
tuberculosis.  The  sufferers  are  usually 
weak  and  wasted;  the  abdomen  is  en- 
larged and  tympanitic,  and  diarrhoea  is  a 
common  symptom.     Some  fever  is  usu- 


Cervico -Bronchial  Lymphatic  System  IBourqery J 

a  a  a  a    Glands  involved  in  bronchial    adenopathy 

ANATOMIE       OU    CORPS      HUMAIN 


ADENITIS.     CHRONIC.     DIAGNOSIS.     ETIOLOGY. 


153 


ally  present.     This  form  may  exist  in 
adults.     (Osier.) 

The    majority    of   children   presenting 
symptoms  of  tuberculosis  also  have  gen- 
eral  adenitis,  the   swollen  glands   being 
felt  everywhere;    they  never  change   in 
size   or   consistence.     Suddenly   a   bron- 
chitis develops,  followed  by  a  broncho- 
pneumonia,  from  which   the   child   dies. 
Microscopical    examination    reveals    ca- 
seous spots  and  the  presence  of  tubercle 
bacilli   throughout   the   affected   glands. 
The    name    of    "generalized    peripheral 
adenitis"    suggested   for   this    condition. 
Grancher  and  Marinescu  (L'Union  M6d., 
Dec.  2,  '90). 
Diagnosis.  —  Chronic  adenitis  is  gen- 
erally  limited   to    one   or   two   glands; 
when  the  glands  are  tuberculous,  chronic 
adenitis  is  apt  to  affect  an  entire  mass. 
The  former  is  often  associated  with  an 
external  simple  lesion;    the  tuberculous 
form  is  apt  to  be  more  frequent  in  chil- 
dren, young  soldiers,  and  negroes. 

Ltmphadenoma. — This  variety  of  tu- 
mor is  usually  more  voluminous  and  is 
not  suppurative.  The  diagnosis,  how- 
ever, is  exceedingly  difficult. 

Simple  Adenitis. — This  is  an  acute 
affection  usually  ending  in  a  few  days  in 
suppuration. 

Syphilitic  Adenitis. — When  a  pri- 
mary sore  is  present,  numerous,  small, 
hard,  indolent  glands  can  be  felt  if  the 
region  is  supplied  with  a  chain  of  lym- 
phatics. WTien  in  secondary  syphilis 
there  is  glandular  enlargement,  a  large 
number  of  external  lymphatics  take  part 
in  the  process. 

Carcinoma. — The  enlarged  glands  are 
small  and  hard,  and  can  generally  be  dis- 
tinctly traced  to  the  growth. 

Ltmphosaecoma.  —  This  persists 
longer  and  is  much  larger  before  degen- 
eration occurs. 

Polyadenitis  is  a  diagnostic  sign  of 
tuberculosis  in  children.  Marinescu  (Re- 
vue Men.  des  Mai.  de  I'Enfance,  Mar., 
'91). 


[As  observed  some  years  ago  by  Huti- 
nel,  the  majority  of  children  presenting 
sj'mptoms  of  tuberculosis  also  have  gen- 
eral adenitis.  The  swollen  glands  are  to 
be  felt  everywhere,  forming  a  general 
adenitis,  and  are  found  in  regions  where 
there  is  no  other  trace  of  tubercular  in- 
volvement. Suddenly  a  bronchitis  de- 
velops, followed  by  broncho-pneumonia, 
from  which  the  child  dies.  Ernest 
Laplace,  Assoc.  Ed.,  Annual,  '92.] 

In  chronic  adenitis  the  glands  may 
become  painful  by  the  compression  of 
small  nerves,  or  of  neighboring  organs; 
when  they  are  inflamed  a  small,  hard 
mass  usually  appears,  either  alone  or 
imited  with  others,  which  may  become 
enlarged  and  suppiirate,  or  persist  with 
practically  no  change  for  years,  or  finally 
disappear  if  the  cause  of  irritation  be 
removed. 

Chronic  adenitis  is  frequently  a  com- 
plication of  malignant  tumors.  Supra- 
clavicular adenitis  appearing  during  the 
course  of  visceral  cancer  is  usually  situ- 
ated on  the  left  side  (foimd  twenty-seven 
times  on  that  side  by  one  author).  It 
may  be  solitary  or  accompanied  by  adeni- 
tis in  other  regions;  it  usually  appears 
late  and  develops  rather  rapidly.  When 
occurring  early  it  may  be  very  useful  for 
diagnostic  purposes. 

Twenty-nine  cases  of  visceral  cancer  in 
which  supraclavicular  adenitis  was  pres- 
ent on  the  left  side  in  twenty-seven.    The 
symptoms  are  not  very  decided  at  first 
and  the  diagnosis  may  be  more  difficult. 
As  to  pathogenesis,  it  must  be   looked 
upon  as  due  to  direct  propagation  or  to 
the  formation  of  a  cancerous  embolism. 
H.  Rousseau   (Paris  Thesis,  '95). 
From   a   clinical  point   of  view  this 
adenitis  may  be  known  by  its  ligneous 
hardness,   its   painlessness,   its   freedom 
from  adhesions,  and  by  the  tinion  into 
one  solid  mass  of  all  the  glands  forming 
it. 

Etiology. — This  form  of  adenitis  fre- 
quently follows  some  neighboring  super- 


154 


ADENITIS.     CHRONIC.    PATHOLOGY. 


ficial  lesion,  such  as  eczema,  impetigo, 
conjunctivitis,  or  the  exanthemata.  Ca- 
tarrhal inflammation  of  the  mucous 
membranes  predisposes  to  tuberculosis 
of  the  glands.  The  resistance  of  the 
lymph-tissue  is  weakened.  This  explains 
the  frequent  development  of  tuberculous 
bronchial  adenitis  after  whooping-cough 
and  measles,  and  of  mesenteric  adenitis 
in  children  with  intestinal  disturbances. 
Cervical  adenitis  is  not  a  manifestation 
of  an  already  generalized  tuberculosis; 
the  bacillus  penetrates,  by  solution  of 
continuity  of  the  mucous  membranes  or 
the  skin,  to  the  ganglion,  which  becomes 
a  seat  of  infection.    (Duhamel.) 

A  distinction  should  be  made  between 
hereditary  (congenital)  and  acquired 
tuberculosis.  In  the  latter  case  the  au- 
thor's views  seem  rational  and  correct, 
being  comparable  with  and  analogous  to 
the  phenomena  observed  in  carcinoma 
and  syphilis.  When  the  infection  is 
acquired  there  is,  at  first,  a  local  seat,  or 
focus,  of  infection  in  which  the  disease- 
germs  develop  and  from  which,  after 
proliferation,  they  spread  until  the  dis- 
ease becomes  more  or  less  generalized, 
— the  germs  being  transmitted  through 
the  lymphatic  system  to  the  lungs  and 
thence  in  the  blood-stream  to  the  various 
organs  of  the  body;  the  various  glands 
along  the  course  or  path  of  transmission 
become  affected  and  in  turn  become  ad- 
ditional possible  foci  of  infection.  On 
the  other  hand,  when  the  trouble  is 
hereditary  the  glandular  manifestation  is 
an  indication  of  an  already  generalized 
tuberculosis. 

Youth  predisposes  to  caseous  adenitis 
on  account  of  the  predominance  at  that 
period  of  the  lymphatic  system.  Crowd- 
ing, humidity,  and  bad  or  insufRcient 
food  are  also  predisposing  factors.  Tu- 
berculous adenitis  is  frequently  observed 
in  temperate  regions.     Negroes  brought 


to  such  climates  are  especially  prone  to 
become  sufferers. 

The  absorbent  power  of  the  lymphatic 
system  is  so  great  that  the  morbific  prin- 
ciple of  tuberculosis  may  be  transported 
to  the  glands  without  visible  external 
lesion  of  the  skin  or  mucous  membrane. 

Axillary  adenitis  is  frequently  second- 
ary to  chronic  tubercular  lesions  of  the 
lungs.    (Lepine.) 

The  cervical  glands  are  occasionally 
found  affected  in  phthisical  patients. 

Proof  of  this  has  been  lacking,  and 
experimental  attempts  to  induce  tuber- 
culosis of  the  cervical  glands  by  intro- 
duction of  tubercle  bacilli  into  the  ton- 
sils have  failed.  J.  Solis-Cohen  (Amer. 
Jour.  Med.  Sci.,  May  9,  '95). 

In  post-mortem  examination  upon 
bodies  of  twenty-five  tubercular  patients 
tuberculosis  of  the  tonsils  was  found  in 
twelve,  in  every  case  in  which  the  lymph- 
glands  of  the  neck  were  also  affected. 
Kruckniann  (Virchow's  Archiv,  B.  138, 
'94). 

A  considerable  proportion  of  the  eases 
of  enlargement  of  the  tonsils  and  of  ade- 
noid vegetations  of  the  pharynx  are 
tuberculous  in  nature.  Dieulafoy  (Lon- 
don Practitioner,  July,  '95). 

A  suppuration  of  cervical  glands  may 
be  derived  from  the  pharynx,  as  a  rule, 
without  tuberculous  lesion  of  that  part. 
Eustace  Smith  (London  Lancet,  May  25, 
'95). 

Instance  of  tuberculous  inoculation 
through  a  small  wound  on  the  chin  by 
kisses  of  tuberculous  mother.  In  this 
case  cutaneous  tuberculosis  was  followed 
by  a  tuberculous  lymphangitis.  Eemy 
(Jour,  de  Clin,  et  de  Ther.  Infantile, 
Mar.  14,  '95). 

[If  the  mother  were  tuberculous,  there 
is  a  reasonable  doubt  that  her  offspring 
was  a  "healthy  child,"  as  stated  in  the 
original    article.     C.    Sumistee   Wither- 

STINE.] 

Pathology. — Usually  an  entire  group 
of  glands  is  affected.  The  glands  are 
isolated  when  the  irritation  and  rapidity 
of  growth  are  not  great;    this  usually 


ADENITIS.     CHRONIC.     PATHOLOGY. 


155 


occurs  in  secondary  visceral  adenitis.  In 
other  cases — especially  when  the  glands 
are  superficial,  where  the  adenitis  is  pri- 
mary— the  glands  are  united  into  a  large 
lobulated  and  irregular  mass,  the  size  of 
which  may  vary  from  that  of  a  small  nut 
to  that  of  an  orange. 

If  the  adenitis  follows  a  visceral  tuber- 
culosis the  afEerent  lymphatics  show,  in 
some  cases,  signs  of  tuberculosis,  as  is 
the  case  in  pulmonary  and  mesenteric 
tuberculous  meningitis. 

Two  varieties  of  lesions  are  to  be 
noted:  1.  Lesions  of  chronic  adenitis 
affecting  the  stroma  and  the  elements  of 
the  gland,  which  becomes  hypertrophied. 
2.  Specific  lesions  of  tuberculosis,  con- 
sisting in  miliary  granulation  at  first, 
ending  in  caseation.  As  one  or  the  other 
of  these  two  processes  is  the  more  promi- 
nent, so  will  the  lesion  vary  in  appear- 
ance. Deep  adenitis  is  never  so  sclerous 
as  the  superficial  variety,  the  latter  being 
characterized  by  a  more  vigorous  reac- 
tion. 

On  section  of  a  gland  in  the  early  stage 
of  tuberculous  infection  we  find  it  redder 
than  usual,  though  at  times  gray  and 
somewhat  translucent.  The  tiibeiculous 
granules  may  be  perceived  by  a  glass. 
They  are  formed  from  the  vascular  and 
Ij'mphatic  vessels  foimd  in  the  cortical 
and  medullary  portions,  and  resemble 
ordinary  follicles,  but  contain  many 
small  cells.  Caseation  rapidly  occurs  in 
them,  beginning  at  the  centre  of  the 
cells,  where  giant-cells  are  first  formed, 
proceeding  to  coagulation-necrosis  and 
caseation.  A  number  of  these  granula- 
tions united  form  the  small,  yellowish 
masses,  which  may  be  seen  by  the  un- 
aided eye.  Caseation  is  due  to  vascular 
obliteration. 

The  small,  yellowish  masses,  softened 
at  their  centres,  are  surrounded  by 
fibrous   tissue   due   to   sclerosis   of   the 


stroma  of  the  gland.  When  this  tissue 
gives  way,  several  masses  form  a  large 
collection  of  yellowish,  softened  material 
resembling  putty.  Calcification  may 
occur  when  the  process  is  very  slow. 

The  specific  lymphadenitis  blocks  the 
lymph-spaces  and  thus,  for  a  time  at 
least,  mechanically  prevents  the  bacilli 
from  penetrating  into  the  general  circu- 
lation. Glands  not  in  the  stream  become 
infected,  this  probably  being  due  to  the 
transportation  by  migrating  cells  of  the 
motionless  bacillus.  However,  infection 
usually  takes  place  in  the  direction  of  the 
lymph-current.  As  the  lymph-spaces  are 
obstructed  by  inflammation  products, 
and  entrance  of  fresh  bacilli  into  the 
gland  is  thus  prevented,  it  is  the  multi- 
plication of  those  already  entered  into 
the  gland  which  gives  rise  to  the  tuber- 
culosis. When  caseation  occurs,  nearly 
all  the  bacilli  have  disappeared,  but  the 
spores  remain,  and  are  capable  of  repro- 
ducing the  disease.  Suppuration  is  due 
to  a  secondary  infection  by  pyogenic 
micro-organisms.     (Senn.) 

The  virus  of  tubercular  adenitis  is 
less  potent,  for  the  caseous  material  of 
a  lymph-gland  kills  guinea-pigs,  while 
rabbits  escape,  the  latter  being  less  sus- 
ceptible to  tuberculous  infection. 

Taken  as  a  whole,  tuberculous  aden- 
itis (a)  is  a  local  disease  which  may 
frequently  undergo  (&)  spontaneous  reso- 
lution, but  which  (c)  frequently  tends  to 
suppuration,  the  pus  being  nearly  always 
sterile.  It  is,  however,  a  constant  danger 
to  the  system. 

Chronic  adenitis  may,  in  some  cases, 
be  due  to  continued  irritation;  ulcers; 
chronic  lesions  of  the  skin  or  mucous 
membrane  of  the  bones:  periosteum; 
articiTlations;  chronic  inflammation  of 
the  viscera;  and  certain  new  growths 
where  the  adenitis  is  purely  irritative 
and  not  yet  specific. 


156 


ADENITIS.     CHRONIC.    PROGNOSIS.    TREATMENT. 


Researches  on  the  relation  existing 
between  caries  of  the  teeth  and  simple 
chronic  and  tuberculous  adenitis  in  chil- 
dren. In  41  per  cent,  of  the  children 
examined  no  etiological  factor  for  cer- 
vical adenitis  found  except  concomitant 
dental  caries.  Caries  of  the  teeth  to  be 
locked  upon  as  relatively  the  most  im- 
portant cause  of  cervical  adenitis  in 
children.  H.  Stark  (Beit.  z.  klin.  Chir., 
vol.  xvi,  No.  1,  p.  61,  '96). 

Prognosis.  —  A  chronic  adenitis  may 
end  in  resolution,  suppuration — casea- 
tion (see  Pathology),  cretaceous  for- 
mation, or  cyst-formation.  If  all  the 
tuberculous  matter  can  be  eliminated, 
either  by  nature  or  art,  a  recovery  may 
be  obtained.  The  deeper  glands  are 
more  dangerous  than  the  superficial,  as 
they  are  extirpated  with  more  difficulty. 
The  great  danger  of  local  tuberculous 
adenitis  is  that  it  may  give  rise  to  other 
tubereiUous  lesions,  either  local  (pulmo- 
nary phthisis,  tuberculous  osteitis,  white 
swellings,  or  abscesses)  or  general  (gen- 
eralized tuberculosis,  with  rapid  death). 

Acute  miliary  tuberculosis  may  be 
caused  in  two  ways:  either  by  convey- 
ance through  the  lymphatic  system  un- 
til the  venous  system  is  reached  or  by 
the  perforation  of  a  vein  and  the  en- 
trance of  tuberculous  material.  (Wei- 
gert.) 

Treatment.  —  The  general  treatment 
should  receive  considerable  attention. 
Good  food,  country  air,  and  sea-bathing 
are  of  the  greatest  value. 

The  sea-shore  advised  for  a  short  time, 
—  not  longer  than  two  months,  —  after 
which  tuberculous  children  fall  back  into 
their  previous  condition  from  loss  of 
appetite.  Iscovesco  (La  Seniaine  M6d., 
Sept.   17,  '90). 

Aeropathy  and  salt-water  baths  are 
useful  in  the  treatment  of  local  tubercu- 
losis. The  children  are  in  the  open  air 
all  day,  playing  on  the  beach.  A  climate 
of  mild  temperature  should  be  selected, 
one  allowing  patients  to  partake  of  the 


baths  surcharged  with  chloride  of  so- 
dium the  year  around.  Of  eight  patients 
suffering  with  Pott's  disease,  coxalgia, 
and  scrofulous  glands,  si.x  were  cured. 
The  others  improved  in  the  course  of  a 
few  months.  Frangois  Hue  (La  Nor- 
mandie  Med.,  Apr.  15,  '91). 
In  peribronchial  adenitis  the  same 
general  methods  are  to  be  resorted  to. 
When  due  to  tuberculosis  and  kindred 
diatheses  and  uncomplicated  by  fever  or 
involvement  of  lung-tissue,  the  sea-shore 
or  the  country  is  indicated.  At  the  sea- 
side children  should  not  bathe  in  the  sea, 
and  should  be  as  quiet  as  is  consistent 
with  life  in  the  open  air.  Brisk  frictions, 
milk,  a  nutritious  diet,  and  iodotannic 
syrup  (2  to  4  teaspoonfuls  per  day)  are 
effectual  measures.  After  three  to  four 
weeks,  emulsion  of  calcium  lactophos- 
phate  and  codliver-oil  should  be  given. 
Counter-irritation  between  the  shoulder- 
blades  favors  the  curative  action  of  the 
other  remedies  (Marfan).  Applications 
of  tincture  of  iodine  between  the  shoul- 
ders, or  in  some  cases  blisters  or,  even 
better,  ignipuncture,  will  fulfill  the  latter 
indications.  Iron-iodide  syrup,  iodotan- 
nic syrup,  iodine  tincture,  potassium 
iodide,  or  large  doses  of  codliver-oil, 
either  alone  or  with  cinchona-wine,  ar- 
senic, or  arseniate  of  sodium  are  the 
standard  remedies  usually  recommended 
in  these  conditions.  Not  much  is  to  be 
expected  from  them,  however,  unless  out- 
door life  is  insisted  upon. 

Every  case  of  cervical  adenitis  coming 
under  observation  tested.  Tuberculin 
used  was  1-per-eent.  solution  of  Koch's 
original  product.  If  in  from  six  to 
twenty-four  hours  after  injection  there 
occurred  weakness,  sensations  of  heat 
and  cold,  general  malaise,  nausea,  ano- 
rexia, severe  headache,  pain  in  back  and 
limbs,  and  if  these  symptoms  were 
sharply  defined  in  both  their  beginning 
and  ending,  reaction  was  considered  to 
have  occurred.  All  cases  were  prac- 
tically without  fever  at  time  of  injec- 


ADENITIS.    CHRONIC.    TREATMENT. 


157 


tions.  No  bad  results  followed.  In  only  | 
one  case  was  reaction  excessive.  It  gen- 
erally occurred  in  from  8  to  14  hours 
after  injection  and  continued  from  12  to 
36  hours.  From  1  to  5  milligrammes  | 
constituted  usual  dose.  On  29  cases 
there  were  positive  reactions  in  18  and 
doubtful  in  2.  In  6  of  11  cases  in  which 
there  was  no  reaction  glands  had  been 
enlarged  only  for  from  1  to  3  weeks. 
In  majority  of  positive  cases  they  had 
existed  for  six  months  or  more.  Of  the 
29  patients  studied,  22  were  females.  In 
17  patients  diseased  glands  were  on  left 
side.  General  and  local  treatment  ad- 
vised in  positive  cases,  local  treatment 
consisting  in  excision  of  glands  when 
possible,  or  free  incision  and  drainage 
when  suppuration  has  taken  place.  Ed- 
ward O.  Otis  (Phila.  Med.  Jour.,  July 
16,  '98). 

Extirpation  is  recommended,  but  the 
possibility  of  giving  rise  to  a  tuberculous 
process  elsewhere  by  facilitating  absorp- 
tion through  exposed  tissues  should  be 
borne  in  mind. 

Senn  states  that  early  operative  inter- 
ference is  as  necessary  in  the  treatment 
of  tubercular  adenitis  as  in  the  treat- 
ment of  malignant  tumors,  and  holds 
out  more  encouragement,  so  far  as  a 
permanent  cure  is  concerned.  Tillmann 
argues  that  glandular  tuberculosis  should 
be  operated  as  soon  as  possible,  in  order 
to  prevent  general  miliary  tuberculosis 
by  the  passage  of  the  bacilli  into  the 
system. 

Immediate  excision  of  infected  glands 
in  tubercular  inguinal  adenitis  advised. 
Brault  (Lyon  Medical,  No.  10,  '94). 

1.  Whenever  fluid — that  is,  pus — can 
be  detected  in  connection  with  a  diseased 
lymphatic  gland,  the  operation  should 
be  done  before  th§  skin  becomes  red  and 
thin.  2.  When  the  diseased  gland  is 
subcutaneous — that  is,  not  beneath  the 
deep  fascia  or  muscle,  and  has  been  com- 
pletely removed — the  least  scar  will  re- 
sult if  neither  stitches  nor  drainage-tube 
be  used,  especially  if  it  be  possible  to 
leave  the  wound  uncovered  by  dressing 


and  exposed  to  the  air,  so  that  the  edges 
may  be  drawn  and  glued  together  by 
drying  lymph.  3.  If  the  diseased  gland 
be  beneath  the  muscle  or  muscular  fascia, 
then  a  drainage-tube  must  be  used  and 
the  edges  of  the  wound  must  be  united 
by  suture.  The  best  drainage-tube  is  the 
gilt  spiral  wire,  especially  as  it  may  have 
to  remain  from  two  to  eight  or  ten  weeks, 
according  to  the  depth  of  the  wound  or 
the  completeness  of  the  removal  of  the 
gland.  4.  Where  many  glands  have  to 
be  removed,  it  is  better  to  remove  them 
through  a  series  of  small  incisions  and 
thereby  avoid  very  extensive  ones.  Con- 
sidering the  subject  from  a  pathological 
point  of  view,  all  sinuses  and  suppurating 
cavities  should  be  thoroughly  cleansed  by 
means  of  scraper  and  lint,  so  as  to  leave 
a  fresh  surface  free  from  granulation  or 
decayed  or  decaying  tissue,  and  a  drain- 
age-exit should  be  maintained  until  all 
the  deep  parts  are  healed.  Teale  (Brit. 
Med.  Jour.,  No.  1717,  '93). 

Extirpation  is  indicated  when  internal 
medication  has  failed;  when  glands  in- 
volve the  face  and  produce  deformity; 
when  they  are  isolated  and  not  numer- 
ous; when  they  have  undergone  fibrous 
degeneration;  when  they  are  not  freely 
suppurating.  It  is  contra-indicated  when 
there  is  impaired  general  health  and 
tubercular  deposits  in  the  lungs  and 
joints;  when  ramifications  of  glandular 
chain  are  very  extensive.  Le  Dentu 
(Revue  Int.  de  Med.  et  de  Chir.,  Sept. 
10,  '95). 

[To  be  of  real  value  extirpation  must 
be  done  before  infection  has  extended 
beyond  the  glands  involved,  else  the  in- 
fection will  proceed,  nevertheless,  to 
generalization.  When  done  later,  it  may 
prevent  that  secondary  infection  which 
follows  from  an  overswollen  or  suppurat- 
ing gland,  and  may  be  of  cosmetic  value; 
that  is,  to  prevent  unsightly  and  exten- 
sive scars.  C.  Sumner  Witheestine, 
Assoc.  Ed.,  Annual,  '96.] 

Sternal  adenitis  falls  into  three  groups 
due  to  the  anatomical  position,  whose 
principal  symptoms  are  as  follow:  I. 
Deep  adenitis;  phenomena  of  constric- 
tion; extension  to  the  mediastinum  and 
the  axilla.    2.  Medium  adenitis;    no  phe- 


158 


ADENITIS.     CHRONIC.     TREATMENT. 


nomena  of  constriction;  position,  sub- 
sternal; deep  cicatrix,  retrosternal.  3. 
Superficial  adenitis;  position,  prester- 
nal.  Maurice  Patel  (Gaz.  Hebdom., 
Sept.  16,  1900). 

Tuberculous  adenitis  of  the  cervical 
region  is  almost  always  local,  and  takes 
place  through  the  buccal  cavity.  A 
suppurating  gland  is  always  dangerous, 
and  should  be  removed  entirely.  Small 
groups  or  single,  slowly  growing  glands 
are  likewise  to  be  removed.  Nature  will 
provide  a  new  and  equally  perfect  pro- 
tection against  external  invasion,  to  take 
the  place  of  the  glands  that  are  lost  by 
operative  procedures.  H.  Horace  Grant 
(N.  Y.  Med.  Jour.,  Oct.  20,  1900). 


Sigmoid  incision  for  the  removal  of  cervical 
glands.     (Senn.) 

After  incision,  thorough  curetting 
followed  by  iodoformization  and  closure 
should  be  performed.  The  wonnd  should 
be  drained.  The  operator  should  not 
only  feel,  but  see,  €Yery  gland  he  re- 
moYes.  In  cervical  adenitis  an  S-shaped 
incision  gives  more  room  and  a  better 
cicatrix.    (Senn.) 

In  other  regions  the  incision  should 
be  made  so  as  to  bring  its  axis  parallel 
with  the  cutaneous  folds.  Local  recur- 
rence should  be  treated  in  the  same  way. 
Three  or  foiir  operations  in  as  many 
years  have  been  performed  by  Senn  on 
the  same  patient,  with  final  successful 
result. 


One  thousand  cases  of  extirpation  of 
tuberculous  glands,  without  a  single  case 
of  pyfemia  or  septicaemia  and  only  two 
cases  of  erysipelas,  in  both  of  which  the 
infection  was  traced  to  a  nurse.  One  of 
the  best  eriterions  of  the  success  is  the 
ever-increasing  number  of  patients  who 
present  themselves  for  operation,  and 
who  nearly  all  enter  the  hospital  asking 
for  the  removal  of  their  enlarged  glands. 
Milton  (St.  Thomas's  Hospital  Reports, 
vol.  viii) . 

Out  of  3.35  children  treated,  the  tuber- 
culous glands  were  removed  in  102.  The 
operated  cases  gave  a  percentage  of  83.34 
cured,  and  the  non-operated  68.77  per 
cent.;  that  is,  14.56  per  cent,  in  favor 
of  the  operation.  Generalization  of  the 
disease  could  be  found  only  in  1  per  cent, 
of  the  cases.  Cazin  (Lyon  M6d.,  Jan. 
11,  "90). 

Five  hundred  and  six  cases:  286  oper- 
ated; 220  medically  treated.  Of  the 
operated  cases  149  were  carefully  fol- 
lowed during  three  years;  93  (62.4  per 
cent.)  have  not  shown  the  least  sign 
of  return  of  the  affection.  In  the  re- 
maining 56  cases  there  was  a  return. 
Of  the  149  non-operated  cases,  28  died 
in  sixteen  years  (18  per  cent.)  from 
general  tuberculosis,  and  14  are  still 
alive,  but  have  developed  pulmonary 
tuberculosis.  Von  Noorden  (Schmidt's 
Jiihrbticher,  July,  '90). 

When  many  glands  are  involved  and 
suppuration  has  occurred,  or  when  peri- 
adenitis is  present,  excision  is  not  to  be 
recommended,  as  extensive  connective- 
tissue  infiltration  renders  it  impossible 
to  remove  all  the  infected  tissue.  Sub- 
cutaneous extirpation  may  be  resorted  to, 
but  the  method  allows  of  but  imperfect 
evacuation  of  the  glandular  contents  and 
can  hardly  be  recommended. 

Subcutaneous  extirpation.  Incision  at 
the  nape  of  neck,  beginning  on  a  level 
with  the  external  auditory  meatus,  1 
centimetre  from  hairy  border,  and  pass- 
ing with  a  slight  convexity  downward 
5  centimetres  backward,  downward 
toward  the  median  line.  Dollinger  (Cent. 
f.  Chir.,  No.  36,  '94) . 


ADENITIS.     CHRONIC.     TREATMENT. 


159 


Drainage  of  the  abscess  is  a  measure 
which  may  be  recommended  for  many 
reasons.  A  small  incision  is  sufficient 
for  all  purposes,  and  there  is  practically 
no  scar  left. 

Observations  upon  170  cases  of  tu- 
berculous cervical  adenitis  show  the 
disease  to  be  more  prevalent  among 
negroes  than  among  whites,  males  pre- 
ponderating over  females  in  the  propor- 
tion of  3  to  2,  the  majority  being  be- 
tween 10  and  30  years  of  age.  A  family 
history  of  tuberculosis  was  present  in 
about  half  the  cases,  though  only  4  per 
cent,  showed  positive  evidence  of  the 
disease  in  the  lungs.  The  condition  is 
regarded  as  a  local  manifestation  of 
infection  through  the  tonsil,  adenoids, 
or  carious  teeth,  and  the  tuberculin  test 
in  diagnosis  was  found  to  be  reliable 
and  harmless.  After  discussing  the 
constitutional,  local,  and  conservative 
operative  treatment  by  curetting,  par- 
tial excision,  and  application  of  iodo- 
form, the  radical  operation  for  removal 
of  all  the  glands  and  surrounding  fat 
is  described  as  follows:  By  a  T-shaped 
incision,  the  long  arm  of  which  curving 
forward  over  the  sterno-mastoid  muscle 
and  starting  from  the  mastoid  process 
joins  the  short  arm  along  the  clavicle, 
the  dissection  is  carried  from  below  up- 
ward and  outward  from  the  middle  line, 
the  external  jugular  vein  being  tied  and 
divided.  The  omohyoid  muscle  is  then 
divided,  and  by  using  it  as  a  retractor 
the  internal  jugular  vein  is  exposed  and 
the  sterno-mastoid  muscle  pulled  aside. 
In  dissecting  out  the  mass  of  glands 
the  greatest  difficulty  is  experienced 
with  the  chain  connecting  the  anterior 
and  posterior  triangles  behind  the 
sterno-mastoid  muscle,  as  the  spinal  ac- 
cessory nerve  passes  through  the  mass 
and  is  generally  very  adherent.  It  is 
only  when  there  is  very  extensive  mis- 
chief that  it  becomes  necessary  to  di- 
vide the  sterno-mastoid  muscle  or  spinal 
1  accessory  nerve,  or  even  to  tie  and 
divide  the  internal  jugular  vein,  and 
these  steps  should  only  be  resorted  to 
when  the  advantages  of  free  exposure 
outweigh  other  considerations.  The 
wound  is  closed  with  a  subcutaneous 
silver   suture   and   drained   at   its   most 


dependent  part  and  the  resulting  scar 
is  usually  slight.  Mitchell  (Bull.  Johns 
Hopkins  Hosp.,  July,  1902). 

Less  radical  measures  sometimes  bring 
about  a  cure.  A  transformation  of  the 
tuberculous  tissues  into  a  sclerotic  mass 
may  be  obtained.  A  solution  of  chloride 
of  zinc  injected  about  the  tuberculous 
foci  excites  a  growth  of  new  fibrous 
tissue,  which  encapsulates  the  diseased 
portion. 

Twenty-three   patients   suffering   with 
joint  and  gland  tuberculosis  treated  in 
this   manner.      Fibrous-tissue    formation 
occurred  in  every  case.    Injections  made 
of  2  to  5  drops  of  a  10-per-cent.  solution 
of  the  zinc  chloride,  and  often  repeated. 
Lannelongue  (Le  Bull.  Med.,  July  8,  '91). 
Solutions  of  iodoform  and  ether,  after 
Verneuil,  in  cases  where  operative  pro- 
cedures are  indicated,  give  a  lasting  cure, 
without    a    cicatrix.      These    injections 
seem  to  exert  a  beneficial  action,  not  only 
on  the  tuberculous  glands  treated,  but 
also  on  those  at  a  distance  from  the  seat 
of  the  injection. 

Impure  glycerin  always  contains  a 
certain  amount  of  formic  acid.  In  the 
treatment  of  tuberculosis  by  the  iodo- 
form-glycerin  injections  the  irritating 
properties  of  the  formic  acid  may  have 
some  share  in  the  curative  effects  of  iodo- 
form emulsions.  Iodoform  itself  in  the 
body  is  converted  by  oxidation  into 
formic  acid  and  hydriodic  acid.  When 
oxidation  is  sufficiently  active  to  decom- 
pose it,  iodoform  is  more  effective  than 
when  oxidation  is  feeble.  Hence  formic 
acid  added  to  iodoform  emulsions  should 
be  effective.  Favorable  results  where 
iodoform  has  proved  ineffective.  In  eases 
of  tuberculous  adenitis  and  in  one  ease 
of  tuberculous  arthritis  of  the  ankle-joint 
formic  acid  used  alone,  the  formate  of 
soda  in  solution  being  injected.  Excel- 
lent results  obtained.  Senger  (Deutsche 
med.  Woch.,  No.  17,  '91). 
Camphor-naphthol  has  proved  valu- 
able in  some  cases. 

It  is  claimed  in  favor  of  camphor- 
naphthol    that    there    is    no    danger    of 


160 


ADENITIS.    CHRONIC. 


intoxication  and  that  the  treatment  is 
almost  painless.  Menard  and  Calot,  how- 
ever, have  reported  cases  of  intoxication 
following  injection  of  camphor-naphthol 
into  abscess-cavities.  The  patient  suf- 
fered from  frequent  rapid  pulse,  loss  of 
consciousness,  and  epileptiform  attacks. 
The  quantity  of  the  drug  injected  was 
about  6  drachms.  This  patient  recov- 
ered. In  another  case,  8  years  of  age, 
1 V2  ounces  of  the  solution  were  injected. 
In  the  third  case,  aged  12,  5  drachms. 
In  the  last  two  cases  life  was  saved  by 
freely  opening  the  cavity  and  washing 
it  out  on  the  first  appearance  of  toxic 
symptoms. 

Camphorated  naphtliol  is  prepared  and 
used  as  follows: — 
IJ  Betanaphthol, 

Camphor,  of  each,  10  parts. 
Alcohol  (60  per  cent.),  40  parts. 
A  few  drops  are  to  be  antiseptically 
injected  here  and  there  throughout  the 
mass  of  indurated  glands.  Courtin 
(Jour,  de  Med.  de  Bordeaux,  May  17, 
'91). 

Of  47  cases  28  were  cured  and  19  im- 
proved. Reboul  (Marseille-medical,  Jan. 
30,  '91). 

Camphorated  naphthol  recommended 
(1)  for  dressings,  (2)  in  cases  of  recur- 
rence after  excision,  (3)  in  cutaneous 
gummata  of  the  face,  and  (4)  in  subjects 
with  an  inoperable  tuberculous  mass.  In 
the  last  cases  the  injections  gave  a  result 
not  obtainable  by  any  other  method. 
Moty  (La  France  Med.,  July  9,  '93). 

Solution  of  lactic  acid  recommended 
as  a  parenchymatous  injection,  beginning 
with  weak  solutions  of  not  more  than 
15-  or  20-per-cent.  strength,  and  gradu- 
ally increasing  to  35-  or  40-per-eent. 
strength.  A  15-per-cent.  solution  of  the 
lactic  acid  alone  generally  causes  con- 
siderable suffering,  but  when  combined 
with  from  2  to  5  per  cent,  of  carbolic 
acid  it  causes  but  little  pain.  Twenty 
or  30  minims  of  the  solution  injected, 
then  withdrawn  after  a  few  minutes,  re- 
peating in  a  week  or  two.  E.  F.  Ingals 
(Inter.  Med.  Mag.,  June,  '96). 


Interstitial  injections,  frequently  rec- 
ommended, usually  fail  or  cause  suppura- 
tion, owing  to  the  fact  that  the  tincture 
of  iodine  is  employed.  Metallic  iodine, 
however,  gives  a  better  result. 

Metallic  iodine  has  a  special  affinity 
for  tuberculous  glands.  Eight  or  ten  ap- 
plications usually  insure  cure,  provided 
the  cavity  is  filled  with  crystals.  Guer- 
monprez  (Gaz.  des  Hop.,  June  25,  '95). 
C.    SUMNEE    WiTHEESTINE, 

Philadelphia. 

ADENOID  VEGETATIONS.     See 

Kaso-phaetns. 

ADENOMA.    See  Tumors. 

ADIPOSIS.  See  Fatty  Heaet  and 
Obesity. 

ADONIS. — Adonis  is  a  ranunculace- 
ous  plant,  closely  related  to  the  anemone, 
growing  wild  in  Europe,  Asia,  and  Africa. 
Several  species  of  adonis  are  employed, — - 
Adonis  vernalis,  A.  cestivalis,  A.  capeusis, 
A.  cupaniana,  and  A.  amurensis, — but 
all  seem  to  possess  the  same  properties, 
although  the  several  varieties  are  vari- 
ously employed  in  the  different  countries 
in  which  they  grow.  In  Eussia,  for  in- 
stance, it  has  long  been  employed  in 
cardiac  diseases,  and  in  Africa  as  a 
substitute  for  cantharides,  the  bruised 
leaves,  when  fresh,  possessing  vesicating 
properties. 

Dose. — An  infiision  of  4  to  8  parts  of 
the  plant  in  200  of  water  may  be  given 
in  tablespoonful  doses  three  or  four  times 
a  day  (Huchard).  The  tincture  may  be 
administered  in  doses  of  ^/„  to  1  drachm. 
Adonidin,  a  glucoside  of  adonis,  is  ad- 
ministered in  doses  varying  from  ^/„o  to 
Vio  grain.  It  acts  more  promptly  than 
digitalis.    (H.  C.  Wood.) 

Physiological  Action. — Adonis  resem- 
bles digitalis  in  its  action  upon  the  heart. 


AGALACTIA. 


161 


It  increases  the  cardiac  energy  and  gives 
rise  secondarily  to  an  increase  of  arterial 
tension.  The  increased  contractions 
eventually  diminish  and  a  period  of  quiet 
follows,  varying  in  duration  with  the 
dose  administered. 

Cervello  isolated  a  glucoside  from 
Adonis  vernalis, — adonidin, — a  yellow 
powder  having  a  bitter  taste,  obtained 
from  the  leaves.  It  is  soluble  in  water 
and  alcohol,  but  insoluble  in  ether  or 
chloroform. 

Inoko  also  obtained  a  glucoside — 
adonin  —  from  the  Japanese  plant, 
Adonis  amunnsis.  This  substance  is 
free  from  nitrogen,  amorphous,  colorless, 
of  a  bitter  taste,  and  soluble  in  water, 
alcohol,  and  chloroform.  The  symptoms 
observed  on  the  heart  of  a  frog  were  pre- 
cisely those  seen  when  digitaline  is  used. 
It  is  about  twenty  times  weaker  than  the 
adonidin  obtained  from  the  European 
Adonis  vernalis. 

Adonis  Poisoning, — In  poisonous  doses 
adonis  paralyzes  the  peripheral  extremi- 
ties of  the  vagus,  tends  to  excite  the  ac- 
celerator system,  and  it  finally  produces 
paralysis  of  the  cardiomotor  nerves. 

Therapeutics.  —  Adonis   is   useful  in 
cases  of  uncompensated  heart  affection 
in  which  grave  circulator)'  disorders  exist. 
The  marked  diuretic  powers  of  the  drug 
cause  it  to  be  of  value  in  cases  of  dropsy 
and  fatty  heart.     It  is  also  valuable  in 
palpitation  dependent  upon  irregular  in- 
hibition and  in  aortic  and  mitral  regurgi- 
tation (Oliver,  Wood).     As  it  does  not 
seem  to  possess  cumulative  tendencies,  it 
may  be  administered  with  more  freedom. 
Adonis   vernalis   used   in    thirty-three 
cases.     It  will  sometimes  succeed  where 
digitalis  has  completely  failed,  but  it  is 
often  not  given  in  sufficiently  large  dose. 
Case  illustrative  of  the  tolerance  of  large 
doses     of     the     infusion.       Boy-Teissier 
(Marseille-medical,  Mar.  30,  'SS). 
Adonis  employed  in  a  large  number  af 


eases  of  different  cardiac  disorders.    One 
drachm  to  one  ounce  of  the  infusion  daily 
constitutes  an  excellent  cardiac  tonic.    In 
fatty   degeneration   of   the   heart   it  in- 
creases diuresis  and  regulates  the  circu- 
lation.    In  many  cases  of  heart  disease 
the   drug   is   effective   when   digitalis   is 
useless      or      injurious.        F.     Borgiotti 
(Deutsche  med.-Zeit.,  Aug.  30,  '88). 
Obesity. — As  a  remedy  for  the  reduc- 
tion of  superfluous  adipose  tissue,  adonis 
aestivalis  has  proved  of  value.    Owing  to 
the  fact  that  it  does  not  possess  a  tend- 
ency to  cumulation,  it  may  be  continued 
for  a  long  time. 

Case    in    which    the    patient   weighed 
342  pounds   and  suffered  severely   from 
dyspnoea    when    the    administration    of 
adonis  was  begun.    After  taking  10  drops 
of   the    tincture    three    times    daily    for 
twelve  days  there  was  a  loss  in  weight 
of  17  pounds,  the  respiration  had  become 
easier,  and  there  was  general  euphoria. 
R.    Kessler    (Amer.    Medico-Surg.    Bull., 
Aug.  15,  '94). 
EpiUpsy. — To  reduce  the  active  cere- 
bral hypersemia  present  during  a  par- 
oxysm, adonis  has  been  recommended, 
owing  to  its  power  of  stimulating  the 
vasoconstrictors.     It  may   be   advanta- 
geously combined  with  the  bromides. 

Several  years  of  the  use  of  adonis 
vernalis  have  shown  its  ability  to  cause 
almost  immediate  cessation  of  the  fits 
in  some  eases.  Bechterew  (Neurol. 
Centralb.,  Dec.  1,  '94). 

AGALACTIA.  —  From  a,  priv.,  and 
yala.  milk. 

Definition. — Absence  of  the  mammary 
secretion  after  parturition.  The  term  is 
generally  understood  as  meaning  defect- 
ive lactation,  especiallj'  as  to  quantity. 

Symptoms. — Absence  of  the  mammary 
secretion  after  labor  is  rarely  observed. 
The  appearance  of  milk  may  be  delayed 
days  and  even  weeks,  but  evidence  of 
functional  activity  usually  appears,  al- 
though frequently  the  quantity  secreted 


162 


AGALACTIA.     ETIOLOGY.     PATHOLOGY.     TREATMENT. 


is  insufficient  or  the  quality  of  the  milk 
is  not  of  a  character  to  afford  sufficient 
or  proper  nourishment  to  the  infant. 

Statistics  of  126  lying-in  women  in  the 
obstetrical  wards  of  the  Halle  clinic  from 
February  to  May,   1895,  inclusive.     Out 
of  the  126  cases,  83    (or  65.9  per  cent.) 
had  sufficient  milk  when  discharged  be- 
tween the  tenth  and  twelfth  days.    Buch- 
mann  (Centralb.  f.  Gynak.,  No.  25,  '96). 
Deficiency  of  secretion  may  occur  from 
the  start  and  continue  throughout  the 
entire  period  of  lactation,  or  it  may  be 
normal  in  amount  at  first  and  gradually 
diminish. 

Etiology.  —  Heredity  is  a  prominent 
factor  in  case  of  tru«  agalactia.  Puech 
has  reported  the  case  of  a  woman  who 
had  given  birth  to  thirteen  children, 
but  whose  breasts,  though  normal,  had 
never  yielded  milk.  Her  mother,  who 
had  given  birth  to  twenty-three  children, 
had  likewise  been  absolutely  sterile  as 
regards  the  secretion  of  milk. 

Case  of  complete  agalactia  in  a  woman, 
aged    25,    primipara,    whose    mother    is 
living  and  in  good  health,  having  borne 
9  children,  3  of  whom  are  now  living;    4 
died  at  about  five  years  of  age,  1  at  eight, 
and  1  at  twelve  months.     The  patient  is 
the  eighth  child,  and  says  her  mother  has 
often  told  her  that  in  none  of  these  puer- 
peria   had   she  any  milk,   although   the 
breasts  were  natural  in  appearance.    The 
patient  has  one  married  sister,  who  at  25 
years  gave  birth  to  a  full-term  child,  and 
she  never  had  a   drop   of  milk   for   her 
baby.     J.    Ives   Edgerton    (Med.    News, 
Feb.  6,  '97). 
General  ill  health  in  which  anemia 
plays  the  leading  role  is  the  most  fre- 
quent cause   of  retarded,   defective,   or 
imperfect  lactation.    Lack  of  confidence, 
on  the  part  of  the  mother,  of  her  ability 
to   nurse;    excitement,   fatigue,   highly 
spiced  food,  overfeeding,  and  insufficient 
sleep  may  be  mentioned  as  the  most  fre- 
quent auxiliary  factors. 

Injudicious     dressing     whereby     the 


mammas  are  compressed,  the  pressure 
interfering  with  their  circulation  and 
proper  nutrition,  is  a  frequent  cause 
of  deficient  lactation.  Advanced  age, 
especially  in  women  who  have  suffered 
frequently  from  miscarriages,  may  also 
be  included  among  the  etiological  fac- 
tors. The  habit  of  weaning  early  or 
avoiding  lactation  tends  to  cause  atrophy 
of  the  breasts  and  to  repress  the  lacteal 
secretion. 

Prolonged  suckling,  specific  affections, 
and  iodide  of  potassium  are  also  consid- 
ered as  causes  of  mammary  atrophy,  and, 
therefore,  of  deficient  lactation  powers. 

Intercurrent  affections,  especially 
when  acute,  frequently  arrest  the  flow 
of  -milk.  High  fever,  when  temporary, 
usually  causes  diminution  of  the  secre- 
tion for  the  time  being,  and  it  may  act 
as  the  primary  factor  of  gradual  cessa- 
tion. 

Pathology,  —  When  there  is  total  ab- 
sence of  mammary  secretion,  both  breasts 
are  usually  affected.  When  the  secretion 
is  only  defective,  the  involvement  of  the 
glands  in  the  pathogenic  process,  local  or 
general,  is  usually  unequal,  one  mamma 
being  less  productive  than  the  other. 
Large  breasts,  owing  to  the  quantity  of 
adipose  tissue  present,  are  more  likely  to 
be  agalactic  than  the  smaller  and  thinner 
ones.  The  ducts  and  glands  are  usually 
found  deficient  in  number  and  size,  while 
the  adipose  tissue  or  the  fibrous  stroma 
is  unduly  abundant. 

Treatment. — The  first  indication  is  to 
carefully  inquire  into  the  cause  of  the 
condition.  In  the  majority  of  cases 
there  is  general  deficiency  in  the  per- 
formance of  metabolic  processes  due  to 
general  physical  apathy.  The  patient 
should,  therefore,  be  provided  with 
nutritious  food  and  appropriate  tonics, 
especially  strychnine,  which  is  peculiarly 
effective  in  these  eases. 


AGALACTIA.     TREATMENT. 


163 


The  bowels  should  be  regulated  by 
proper  dieting  and  massage  or  exercise 
rather  than  by  laxatives,  and  it  is  highly 
desirable  that  there  should  be  at  night 
uninterrupted  sleep  for  six  hours  for 
mother  and  child. 

Galactagogues  are  valueless  in  the  ma- 
jority of  cases,  most  of  them  exerting 
practically  no  influence  upon  the  gland. 
Occasionally  a  slight  stimulating  effect 
may  be  noted,  but  this  lasts  only  a  short 
time,  and  the  organ  soon  lapses  into  its 
former  torpor. 

Beer,  ale,  porter,  and  other  malt 
liquors,  especially  alcoholic  beverages, 
are  more  hurtful  than  beneficial,  and 
what  improvement  may  show  itself  is 
due  mainly  to  the  confidence  in  the  bev- 
erage taken,  through  the  agency  of  auto- 
suggestion. The  quantity  of  milk  may 
be  increased,  but  its  quality  is  compro- 
mised, especially  when  poor  beer  is  con- 
sumed by  the  mother.  It  encourages  the 
production  of  fat  at  the  expense  of  the 
casein  or  milk-sugar.  Pure  malt  may  be 
substituted  with  great  advantage. 

It  is  an  error  to  suppose  that  stout  or 
porter  improves  milk.     Another  error  is 
the  belief  that  beef-tea  and  chicken-broth 
are    good    for    nursing    mothers.      Angel 
Money  (Austral.  Med.  Gaz.,  Jan.  20,  '97). 
Somatose    exercises    a    specific    effect 
upon   the   mammary  glands   of   nursing 
mothers;    it  produces  an  ample  secretion 
of  the  mother's  milk,  and  causes  the  ail- 
ments occurring  during  nursing  to  disap- 
pear quickly.    The  dose  consists  of  1  tea- 
spoonful  in  a  cup  of  warm  milk,  soup, 
cocoa,  etc.,  from  three  to  four  times  a 
day.     Felix  Heymann   (Deut.  med.-Zeit., 
Nos.  59,  63,  '98). 
Probably  the  mcst  satisfactory  among 
the    galactagogues    is    jaborandi.      The 
fluid   extract   or  the   tincture   may   be 
given  in  ^/o-drachm  doses.     The  active 
perspiration  and  salivation  produced  are 
objectionable,  however,  while  the  effects 
of  the  remedy  are  not  lasting. 


Case  where   the   administration   of   10 
drops  of  the  fluid   extract  of  jaborandi 
every  four  hours  to  a  patient  whose  milk 
had  ceased  for  a  fortnight  effected  a  re- 
establishment  of  the  secretion.     The  pa- 
tient, however,  soon  began  to  suffer  from 
extreme  nervous  excitement  with  delu- 
sions.    On   stopping   the   jaborandi    the 
nervous    and    mental    symptoms    disap- 
peared and   also   the   secretion  of  milk. 
Waugh  (Lancet,  Dec.  24,  '87). 
Castor-oil   leaves   have   always   borne 
considerable  reputation.    A  decoction  is 
made  by  boiling  well  a  handful  of  them 
in  3  to  4  quarts  of  pure  water.     The 
breasts  are  bathed  with  this  decoction 
for  fifteen  to  twenty  minutes.     Part  of 
the  boiled  leaves  is  then  thinly  spread 
over  the  breast  and  allowed  to  remain 
until  all  moisture  has  been  removed  from 
them  by  evaporation,  and  probably,  in 
some  measure,  by  absorption.     The  pro- 
cedure is  repeated  at  short  intervals  until 
the  milk  flows  upon  suction  by  the  child, 
which  it  usually  does  in  the  course  of  a 
few  hours.    (Eouth.) 

Galega  is  credited  with  galactagogue 
properties,  Va  to  1  drachm  of  the  dried 
leaves  being  administered  daily. 

Electricity  sometimes  proves  effective. 
A  mild  current  (3  to  5  milliamperes)  is 
passed  through  each  breast  after  care- 
fully wetting  the  sponges  in  salt-water 
and  applying  them  on  each  side  of  the 
gland.  By  changing  the  position  of  the 
electrodes,  every  minute  or  so,  to  a 
neighboring  spot,  all  the  acini  may  be 
traversed  by  the  current  during  a  sitting 
■of  ten  minutes.  The  applications  should 
be  made  every  two  or  three  hours.  A 
strong  current  is  more  hurtful  than 
beneficial.  Artificial  suction  with  the 
breast-pump  and  massage  are  greatly 
used.  The  extract  of  thyroid  gland  has 
recently  given  very  satisfactory  results. 
Nine  cases  showing  the  value  of  thy- 
roid-gland extract  as  a  galactagogue,  the 
object  being  to  increase  the  activity  of 


1G4 


AGALACTIA. 


the  metabolic  processes.     In  one  of  the 
cases  the  administration  of  four  tabloids 
was  sufficient  to  restore  the  lacteal   se- 
cretion, which  continued  as  long  as  the 
tabloids  were  regularly  taken.     Neglect 
of  the  tabloid  caused  the  milk  to  fail.    In 
six   cases    the   milk-supply    returned    in 
three  days  and  became  plentiful.    In  two, 
no  influence  on  the  milk  observed,  the 
patients    being    delicate,    nervous,    and 
worn  out.     E.  R.  Stawell   (Intercolonial 
Med.  Jour.,  Apr.  20,  '97). 
As  to  the  diet,  it  should  he  as  gen- 
erous as  the  patient  can  digest.     There 
is  little   to  be  gained  by  the   common 
practice  of  prescribing  two  or  three  extra 
meals  a  day.     The  milk-supply  as  well 
as  the  general  health  of  the  woman  will 
depend  more  upon  what  she  digests  and 
assimilates  than  upon  the  amount  of  food 
taken  into  the  stomach.     Three   daily 
meals  with,  at  most,  a  single  liquid  meal 
at  bed-time,  will  generally  be  better  than 
&Ye  or  six.     Milk  should  constitute  a 
portion  of  the  dietary.    The  difficulty  in 
digesting  milk,  of  which  many  patients 
complain,  is,  for  the  most  part,  imagi- 
nary.   If  taken  as  a  part  of  the  meal  and 
not  in  addition  to  it,  it  will,  as  a  rule, 
be  well  borne.    Frequently  patients  who 
•cannot  use   cold  milk  can  take  it  hot 
without  difficulty. 

The  secretion  of  milk  is  said  to  be 
greatly  diminished  by  fatty  food.  A 
vegetable  diet  reduces  the  proportion  of 
butter  and  casein  and  diminishes  the 
sugar.  A  meat  diet  has  the  opposite 
effect.  Systematic  nursing  with  strict 
obseryance  of  stated  intervals  is  essential 
for  its  influence  upon  both  the  quantity 
and  quality  of  the  milk-secretion. 
{Charles  Jewett.) 

C.    SUMNEE   "WlTHEESTINE, 

Philadelphia. 

AG  ASIC  IN.  —  Agaricin  is  obtained 
from  white  agaric.  It  is  a  white,  crys- 
talline powder,  soluble  in  alcohol,  and 


but  slightly  so  in  cold  water  and  ether. 
Agaricic  acid,  the  pure  active  principle 
of  agaricin,  is  generally  used. 

Dose. — The  dose  of  agaricic  acid  is  ^/„ 
to  V2  grain,  administered  in  pills.  Hypo- 
dermically  its  effects  are  more  active  and 
the  dose  should  be  one-half  smaller. 

Physioloi^cal  Action. — ^The  physiolog- 
ical effects  of  this  drug  are  not  known, 
but  they  are  supposed  to  resemble  those 
of  pilocarpine,  or  to  act  mainly  upon  the 
nervous  supply  of  the  sweat-glands. 

Agaricin  checks  pathological  sweating, 
not  by  a  central  action,  but  by  directly 
influencing   the   glands   themselves.      In 
this    only    does    it    resemble    atropine. 
Small  doses,  Vs  to  'A  grain,  preferred  to 
a  single  large  dose.     The  action  is  slow, 
but  lasts  a  long  while.    Hofmeister  (Ar- 
chiv  f.  Exp.  Path,  und  Pharm.,  vol.  xxv, 
'89). 
Therapeutics.  —  Agaricin  is  especially 
valuable  in  the  treatment  of  the  night- 
sweats  of  phthisis.    If  the  gastric  diges- 
tion is  good,  it  will  be  well  tolerated  and 
produce  its  effects  in  from  two  to  six 
hours.     Administered  before  retiring,  it 
sometimes  acts  as  a  preventive  of  the 
exhausting    perspiration    attending    ad- 
vanced cases.     It  is  not  effective  in  all 
cases,  however.    (Hare,  Butler.) 

Sweat  is  always  decreased,  thirst  and 
the  excretion  of  the  urine  are  dimin- 
ished, the  functions  of  the  lungs  and 
skin  are  not  interfered  with,  and  there 
are  no  bad  efi:eets.  The  administration 
of  pure  agaricic  acid  greatly  lessens  the 
danger  of  vomiting  and  purging.  The 
subcutaneous  injection  of  the  soluble 
sodium  salts  should  not  be  used,  as  vio- 
lent inflammation  may  follow.  W.  T. 
Thackeray  (Chicago  Med.  Jour,  and  Ex- 
aminer, June,  '89). 

Seventeen  cases  in  which  agaricin  was 
found  to  possess  most  excellent  anti- 
sudorifle  properties,  the  effect  being  pro- 
nounced not  only  in  tuberculosis,  but  in 
other  forms  of  poisoning  and  infection. 
This  agent,  even  in  the  third  stage  of 
pulmonary    tuberculosis,    was    able     to 


AGARICIX. 


165 


suppress  the  distressing  night-sweats,  its 
action  being  manifested  in  from  two  to 
six  hours  after  the  ingestion  of  the  drug 
and  lasting  about  six  hours.  No  evil 
after-effects  of  any  kind  were  observed. 
The  dose  employed  was  from  'A  to  Vi 
grain  in  pill  form.  Combemale  (Bull. 
G6n.  de  Th6r.,  May  30,  '91). 

Agaricin  most  successful  of  all  drugs  in 
combating  night-sweats  in  phthisis.  Its 
active  principle,  agaricic  acid,  may  be 
used  in  ^Z,-  to  1-grain  doses.  Method  of 
administering  which  has  given  most  ex- 
cellent results  is  as  follows:  Give  Vs 
grain  at  first  dose  and  follow  with  Vs 
grain  every  four  hours  until  the  sweating 
is  checked,  then  continuing  its  use — but 
lengthening  the  interval — until  the  small- 
est quantity  necessary  to  control  sweat- 
ing is  reached.  Eufus  D.  Boss  (Amer. 
Therap.,  Mar.,  '98). 
Minute  doses  are  sometimes  as  effect- 
ive as  the  larger  ones,  and  had  better  be 
tried  before  resorting  to  the  full  doses. 

Agaricin  in  pill  form,  in  doses  of  'A, 
grain  at  bed-time,  or  given  late  in  the 
afternoon  and  repeated  in  four  or  five 
hours,  was  the  most  successful  of  all  the 
drugs  used  in  the  night-sweats  of  pul- 
monary tuberculosis.  Conkling  (Brook- 
lyn Med.  Jour.,  July,  '94). 

AGRAPHIA.     See  Aphasia. 

AINHUM.  —  African  word  meaning 
"to  saw  ofE." 

Definition.  —  Ainhum  is  a  disease  oc- 
curring exclusiTcly  in  negroes  and  con- 
sisting in  the  spontaneous  amputation  of 
the  little  toe  by  an  adventitious  fibrous 
band. 

Symptoms. — The  first  indication  of  the 
disease  is  a  furrow  on  the  lower  surface 
of  the  little  toe,  and  occasionally  other 
toes,  at  the  proximal  interphalangeal 
joint.  This  furrow,  the  result  of  the 
circumferential  pressure  exerted  by  a 
fibrous  ring,  gradually  deepens  until  the 
bone  is  reached,  this  process  taking  sev- 
eral years,  sometimes  as  many  as  ten. 


The  distal  portion  of  the  toe  becomes 
greatly  hypertrophied,  then  finally  drops 
off,  the  stump  healing  without  further 
complication  in  the  great  majority  of 
eases.  It  does  not  give  rise  to  much  suf- 
fering, owing  to  its  very  gradual  progress. 
It  is  sometimes  mistaken  for  leprosy. 

Ainhum    is    an    affection    apart    from 
leprosy.     Cases   of   circular    constriction 
in    leprosy   are   exceedingly    uncommon, 
are  always  located  on  the  fingers,  and 
are  always  accompanied  by  other  morbid 
manifestations,  which  indicate  a  more  or 
less  intense  infection  of  the  blood  by  the 
virus  or  a  localization   of  the  affection 
in  the  nerves,  the  skin,  or  the  mucous 
membrane.    H.  de  Brun  (Bull,  de  I'Acad. 
de  Med.,  Aug.  25,  '96) . 
Etiology. — Ainhum  is  always  observed 
in    negToes,    especially    of    the    western 
coasts  of  Africa  and  South  America.    A 
number  of  cases  have  also  been  reported 
in  the  United  States  by  Bringier.    Hin- 
doos are  said  to   also   suffer  from  this 
disease.     Self-mutilation  has  been  sug- 
gested by  some  observers,  but  the  like- 
lihood   of    this    cause    is    very    slight. 
Heredity  does  not  seem  to  play  any  role 
in  its  production. 

Pathology.  —  The  lesions  observed 
have  been  hypertrophic  thickening  and 
retraction  of  the  derma,  with  consequent 
atrophy  of  the  underlying  bone  (Her- 
mann, Weber,  Wucherer,  Schllppel).  It 
has  been  confounded  with  congenital 
amputation,  but,  as  stated,  ainhum  is 
never  congenital.  That  the  disease  bears 
some  connection  with  leprosy  is  insisted 
upon  by  some  authorities. 

In  all  cases  of  true  ainhum  undoubted 
symptoms  of  leprosy  are  present.  It 
should  be  looked  upon  as  an  attenuated 
form  of  the  latter  disease.  Its  relations 
to  scleroderma  are  explained  by  the  fact 
that  this  latter  affection  is  a  special  for>3 
of  leprosy.  Zambaco  Pacha  (Bull,  de 
I'Acad.  de  M6d.,  July  28,  '96). 
Treatment.  —  Surgical  measures  alone 
prove   of   value   in   these   cases.      Early 


166 


AIROL.     PEEPAKATIOXS.     POISONING.     THERAPEUTICS. 


section  of  the  fibrous  ring  is  sometimes 
sufficient  to  arrest  the  progress  of  the 
disease  or  division  of  the  skin  down  to 
the  periosteum  on  the  opposite  of  the 
seat  of  disease  may  be  resorted  to. 

Case  successfully  treated  by  dividing 
the  skin  and  all  the  tissues  down  to  the 
periosteum,  on  the  side  opposite  to  the 
seat  of  the  disease.  Murray  (Lancet, 
Jan.  30,  '92) . 

AIEOL. — Airol  is  a  compound  of  der- 
matol  and  iodine  discovered  and  intro- 
duced by  Llidy  as  a  substitute  for  io- 
doform. It  occurs  as  a  tasteless  and 
odorless  powder,  unaffected  by  light,  and 
containing  44.5  per  cent.  BioOj  and  24.8 
per  cent,  of  iodine;  its  color  is  gray- 
green,  but  moist  air  or  the  discharge 
from  a  wound  rapiidly  converts  it  into  a 
red  substance,  with  liberation  of  iodine. 
It  is  insoluble  in  ordinary  reagents,  but 
readily  dissolves  in  strong  caustic  soda 
or  weak  mineral  acids. 

Preparations  and  Dose, — The  powder 
is  employed  in  the  same  manner  as  iodo- 
form in  the  treatment  of  superficial 
lesions. 

It  has  also  been  used  dissolved  in  glyc- 
erin, but  Aemmer  has  recently  shown 
that  the  poisonous  efEects  of  the  drug 
were  thus  increased. 

Bruns,  of  Tiibingen,  recommends  airol 
paste  as  an  ideal  dressing  for  sutured 
wounds.  It  dries  rapidly  and  adheres 
closely;  it  is  powerfully  antiseptic,  and 
absolutely  unirritating  to  the  most  sen- 
sitive skin;  but  its  chief  advantage  is 
that  it  permits  the  secretions  to  ooze 
through  it.  He  has  used  it  for  six 
months,  especially  after  laparotomies, 
herniotomies,  and  ignipunctures,  and  did 
not  observe  an  instance  of  stitch-hole 
suppuration  with  it.  He  concludes  that 
occlusion  with  airol  paste  furnishes  the 
simplest  means  of  obtaining  healing  by 
first  intention.     His  formula  is:    Airol, 


mucilaginous  gum  arable,  glycerin,  of 
each,  10  parts;  bolus  albus,  20  parts. 
He  employs  it  even  in  wounds  with 
drainage. 

Airol  Poisoning.  —  The  untoward  ef- 
fects of  airol  were  recently  shown  in  a 
case  treated  by  Aemmer:  after  using 
injections  of  iodoform-oil  without  benefit 
in  an  abscess  resulting  from  hip  disease, 
this  surgeon  evacuated  the  pus  and  in- 
jected 9  drachms  of  a  10-per-cent.  emul- 
sion of  airol  in  equal  parts  of  olive-oil 
and  glycerin.  The  immediate  efEects 
were  acute  local  pain,  headache,  and 
coryza;  but  three  days  afterward  symp- 
toms of  bismuth  poisoning  supervened: 
foetid  breath,  blackish  line  on  the  gums; 
swelling,  tenderness,  and  idceration  of 
the  lips,  gums,  and  pharynx  interfering 
with  mastication  and  deglutition;  head- 
ache, anorexia,  nausea,  and  prostration. 
To  relieve  these  symptoms,  which  were 
becoming  more  serious,  it  was  necessary 
to  open  the  abscess  and  remove  the  emiil- 
sion  of  airol.  The  patient  rapidly  grew 
better,  but  a  slate-colored  pigmentation 
of  the  buccal  mucous  membrane  per- 
sisted for  a  month.  Aemmer  has  found 
that  a  certain  quantity  of  airol  is  dis- 
solved by  glycerin,  and  that  intoxication 
is,  no  doubt,  favored  thereby.  It  is, 
therefore,  better  not  to  use  glycerin  in 
combination  with  airol.  Goldfarb  has 
also  drawn  attention  to  the  fact  that 
applications  of  airol  are  sometimes  very 
badly  tolerated.  Zelenski  found  that  its 
use  on  a  burn  was  followed  by  intense 
jDain  and  the  formation  of  large  bullae 
containing  yellow  fluid,  and  that  a  sup- 
pository containing  3  grains  of  airol 
introduced  into  an  anal  fistula  caused 
suffering  comparable  to  the  red-hot  iron. 

Therapeutics.  —  The  delay  in  the 
growth  of  organisms  produced  by  airol 
is  slightly  greater  than  that  resulting 
from  iodoform,  and  infinitely  more  than 


AIROL.     THERAPEUTICS. 


167 


the  effect  of  dermatol.  It  is  found  that 
the  iniluence  of  antiseptic  powders  is 
greater  the  earlier  their  use  is  com- 
menced; in  acute  phlegmonous  proc- 
esses, however,  they  do  but  little  good, 
while,  the  more  chronic  the  inflamma- 
tion, the  better  the  results  obtained, 
whence  their  special  indication  in  tuber- 
culosis. The  two  great  advantages  in 
this  respect  which  airol  has  over  iodo- 
form are:  first,  the  fact  that  a  small 
quantity  of  its  iodine  is  liberated  as  soon 
as  it  comes  in  contact  with  the  tissues, 
and,  secondly,  that  the  presence  of  bis- 
muth exercises  a  powerful  desiccating 
influence  upon  the  secretion,  thereby 
greatly  aiding  antisepsis. 

Two  thousand  cases  treated  with  airol 
not  one  of  which  showed  sign  of  bismuth 
poisoning.  Airol  gauze  (20  per  cent.) 
also  employed  as  a  dry  dressing.  Its 
value  is  particularly  striking  in  super- 
ficial lesions,  such  as  ulcers  and  burns. 
In  tuberculous  abscesses  the  form  em- 
ployed is  a  10-per-cent.  emulsion  in  equal 
parts  of  glycerin  and  water.  It  is  ex- 
tremely bulky,  being  four  times  as  light 
as  iodoform,  and  twice  as  light  as  derma- 
tol. Haegler  (Brit.  Med.  Jour.,  Apr.  24, 
'97). 

In  treating  wounds  the  paste  is  per- 
fectly unirritating  and  non-toxic,  dries 
rapidly,  and  adheres  firmly,  and  pos- 
sesses hygroscopic  and  antiseptic  quali- 
ties which  render  it  superior  to  any 
other  preparation.  The  paste  is  equally 
adapted  to  all  parts  of  the  body,  and 
the  dressings  cannot  become  loose  or 
movable.  V.  Bruns  gives  the  following 
formula:  — 

R  Airol,  1  drachm. 
Mucilage,  2  drachms. 
Glycerin,  2  drachms. 
Argilla  alba  (kaolin),  sufficient  to 
make  a  soft  paste. 

If  the  paste  becomes  too  dry,  glycerin 
may  be  added;  if  it  be  too  soft,  kaolin 
should  be  rubbed  up  with  it.  No  metal 
instruments  should  be  employed  in  pre- 
paring   the    paste,    since    many    metals 


liberate  iodine  from  airol.  For  the  same 
reason  no  water,  but  always  glycerin,  is 
to  be  used  in  the  preparation.  The 
paste  is  preserved  in  well-stoppered  glass 
or  porcelain  jars,  which  are  not  to  be 
left  open  after  use.  Honsell  (Deut.  med. 
Woch.,  xxvii,  No.  17,  1901). 

Disorders  of  the  Skin.  —  It  is  in 
this  class  of  affections  that  airol  is  most 
effective.  In  ulcers,  eczema,  and  inter- 
trigo its  beneficial  influence  has  been 
conspicuous.  Leprosy  has  recently  been 
added  to  the  list.  One  case,  however, 
is  hardly  sufficient  to  warrant  much 
confidence. 

Remarkable  improvement  in  a  case  of 
typical  leprosy  of  five  years'  standing, 
consequent  on  the  use  of  airol  dusted  on 
the  ulcers  and  open  abscesses,  together 
with  a  10-per-cent.  vaseliu  ointment  ap- 
plied to  the  conjunctivse  and  injected 
into  localities  where  softening  had  com- 
menced. Tonics  were  also  prescribed  and 
general  massage  practiced.  The  drug  was 
well  borne,  but  the  gums  became  dis- 
colored by  the  bismuth  in  the  airol,  and 
when  very  large  doses  were  given  a  cer- 
tain degree  of  prostration  was  observed. 
Fornara  (Lancet,  July  3,  '97). 

DiARRHCEA. — Airol  has  recently  been 
tried  by  Italian  ph3'sicians  in  the  treat- 
ment of  diarrhoea,  the  alterative  prop- 
erties of  iodine  and  the  antiseptic  action 
of  bismuth  having  suggested  its  employ- 
ment. The  effects  seem  to  have  been 
satisfactory. 

In  9  instances  of  pellagrous  intestinal 
disease,  airol,  in  5-  to  8-grain  doses,  fre- 
quently repeated,  gave  excellent  results. 
Not  only  its  astringent  properties  should 
be  mentioned,  but  its  iodine  content  ap- 
pears to  be  responsible  for  the  greater 
part  of  its  good  effects.  F.  Cerato  (Gaz. 
degli  Osped.  e.  delle  Clin.,  No.  142,  p. 
1502,  '98). 

Suppurative  Processes. — In  condi- 
tions accompanied  by  the  destruction  of 
tissue  by  suppuration — boils,  carbuncles, 


168 


AIROL. 


ALBUMINURIA. 


etc. — airol  seems  to  be  entitled  to  recog- 
nition as  a  valuable  remedy. 

GoNOERHCEA.  —  The  known  value  of 
bismuth  in  the  treatment  of  catarrhal 
disorders  of  mucous  membranes  due  to 
local  infection  and  the  alterative  effect 
of  iodine  tend  to  support  the  claims  of 
airol  as  an  effective  remedy  for  gonor- 
rhoea. 

Four  cases  of  gonorrhoea  completely 
cured  after  three  to  five  injections  of  an 
airol  solution.  The  anterior  urethra  is 
first  washed  with  a  borio-aeid  solution. 
Two  and  one-half  drachms  of  the  follow- 
ing solution  are  then  injected: — 

IJ  Airol,  30  grains. 
Glycerin,  '/s  ounce. 
Water,  75  minims. 

This  procedure  is  repeated  four  or  five 
days  in  succession.  Legueu  and  Levy 
(Revue  de  Thgr.,  May  15,  '96). 

Special  attention  called  to  the  value  of 
a  10-per-cent.  emulsion  of  airol  in  glyc- 
erin as  injection  in  gonorrhoea.  Used  in 
three  cases  of  acute  and  three  of  chronic 
gonorrhoea,  all  of  which  have  recovered 
in  ten  to  fourteen  days  after  three  to  ten 
injections,  never  repeated  more  often 
than  once  daily.  No  toxic  efi'ects  were 
observed.  Tausig  (Wiener  med.  Presse, 
Oct.  11,  '96). 


ALBUMINURIA.  —  From  Lat.,  aTbu- 
min;   and  Gr.,  oiiped',  to  pass  the  urine. 

Definition. — The  presence  of  albumin 
in  the  urine.  Albuminuria  may  be  true 
— when  the  albumin  is  dissolved  in  the 
urine — or  spurious,  when  caused  by  ad- 
mixture of  semeUj  pus,  or  blood  in  the 
urine.  Spurious  albuminuria  is  easily 
distinguished  from  the  true  form  by  the 
aid  of  the  microscope.  Both  kinds  of 
albuminuria  may  occur  simultaneously. 

Domenico  Botugno  discovered,  in 
1770,  that  urine  may  contain  albumin; 
by  boiling  a  sample  of  urine  he  foimd 
that  pure  albumin  was  precipitated.     It 


was  long  maintained  by  all  authors  that 
albuminuria  has  always  been  a  symptom 
of  disease,  but  of  late  many  authorities 
have  admitted  that  albuminuria  may  be 
compatible  with  perfect  health. 

Posner  maintains  that  albumin  is 
always  found  in  the  urine,  but  normally 
in  too  small  quantity  to  be  revealed  by 
the  ordinary  reagents.  To  demonstrate 
the  presence  of  albumin  in  normal  urine 
Posner  evaporated  large  quantities  of 
urine  at  low  temperature  and  tried  the 
different  reagents  in  the  concentrated 
urine.  His  experiences  have  been  re- 
peated and  his  views  supported  by 
Senator  and  by  Leube,  who,  however, 
did  not  find  albumin  in  all  cases.  Von 
Noorden,  Winternitz,  Lecorche,  Tala- 
mon,  and  different  other  authors  do  not 
admit  that  albumin  is  a  constituent  of 
the  normal  urine.  At  any  rate,  only 
traces  of  albumin  can  be  considered  as 
physiological. 

Different  kinds  of  albumin  may  be 
present  in  the  urine;  generally  the  pro- 
teids  contained  in  the  blood-serum  are 
to  be  found, — viz.:  (1)  the  serum-albu- 
min, or  serin,  and  (2)  the  globulin,  or 
paraglobulin;  in  most  cases  both  these 
proteids  are  present,  but  in  varying  pro- 
portions. In  some  cases  there  may  also 
be  found  (3)  hemialbumose,  or  propep- 
ton,  a  mixture  of  different  albumoses 
which  are  not  precipitated  by  boiling; 
(4)  nucleo-albumin,  which  has  also  er- 
roneously been  called  "mucin";  and  (5) 
pepton. 

Five  proteids  are  found  in  the  urine, 
viz.:  (1)  serum-albumin;  (2)  serum- 
globulin;  (3)  nucleo-albumin,  or  mucin; 
(4)  pepton;  (5)  albumose,  or  propep- 
ton.  The  first  two  are  of  special  im- 
portance because  of  their  association 
with  nephritis.  Mucin  is  usually  present 
normally  in  small  amount  in  the  urine. 
Pepton  and  albvimose  should  never  ap- 
pear  in   normal    urine.      Serum-albumin 


ALBUMINURIA.     PHYSIOLOGICAL. 


169 


in  the  urine  may  be  due  to  (1)  renal 
disease  or  (2)  to  the  pressure  of  pus, 
spermatozoa,  blood,  or  elements  of 
tumors.  Urine  containing  these  sub- 
stances will  give  the  albumin-reaction. 

Renal  albuminuria  may  be  divided 
etiologically  into  (1)  that  following  cer- 
tain febrile  diseases;  (2)  nervous  albu- 
minuria, following  some  diseases  of  the 
central  nervous  system;  (3)  hsemato- 
genetie  albuminuria;  (4)  toxic  albu- 
minuria; (5)  albuminuria  of  pregnancy; 
(6)  congestive  albuminuria;  (7)  albu- 
minuria due  to  long-continued  exposure. 
The  appearance  of  pepton  in  the  urine 
is  pathological.  It  is  expected  in  cases  of 
empyema  or  other  extensive  pus-for- 
mations: (I)  the  ulcerative  stage  of 
typhoid  fever,  (2)  suppurative  processes, 
(3)  pneumonia  at  the  crisis,  (4)  after 
childbirth,  (5)  in  carcinomatous  affec- 
tions, and  (6)  in  phosphorus  poisoning. 
T.  P.  Prout  (Phila.  Med.  Jour.,  Feb.  10, 
1900). 

The  urine  may,  of  conrse,  also  contain 
albumin  in  connection  with  hsematima 
and  hemoglobinuria,  but  such  cases  can- 
not be  classed  as  true  albuminuria. 

Physiological  Albuminuria. — Eegard- 
ing  the  origin  of  the  albumin  in  the 
urine  only  guesses  can  be  made;  two 
theories  are  possible:  (1)  the  albumin 
may  come  from  the  glomeruli;  (2)  from 
the  tubular  epithelial  cells. 

Formerly  the  opinion  predominated 
that  the  fluid  which  escaped  from  the 
glomeruli  was  albuminous,  but  that  the 
albumin  was  absorbed  during  the  passage 
through  the  healthy  renal  tubules,  dis- 
eased tubular  epithelium  being  unable 
to  absorb  the  albumin.  This  has  not 
been  proved,  however,  and  most  modern 
authors  believe  that  albumin  is  not 
contained  in  the  urine  coming  from 
the  glomeruli,  except  when  these  are 
diseased  or  when  the  pressure  of  blood 
in  the  glomeruli  is  abnormally  great. 
Euneberg,  on  the  contrary,  is  of  the 
opinion  that  albuminuria  is  caused  by 


low  pressure  of  blood,  and  supports  this 
opinion  by  experiments  with  animal 
membranes,  but  experiences  with  dead 
membranes  cannot  be  regarded  as  con- 
clusive for  the  action  of  the  living 
kidney. 

Von  Noorden  and  different  other  au- 
thors regard  the  tubular  epithelium  as 
the  unique  source  of  albuminuria.  These 
epithelial  cells  are  subject  to  successive 
disintegration:  when  this  is  minimal 
and  successive  traces,  only,  of  albumin 
are  found  in  the  urine,  the  albuminuria 
is  physiological;  when  the  decaying  of 
the  tubular-epithelial  cells  is  augmented 
and  quickened  by  disease,  a  morbid  albu- 
minuria takes  place.  In  his  opinion,  this 
theory  is  supported  by  the  fact  that 
nucleo-albumin,  of  which  the  protoplasm 
of  the  cells  undoubtedly  is  the  source,  is 
always  found  in  normal  urine. 

Nucleo-albuminuria  always  arises  from 
the  disintegration  of  the  nuclei  of  cells 
that  are  shed  on  account  of  a  lesion  of 
the  renal  epithelium  or  of  an  irritation  of 
the  vesicle  and  genito-urinary  epithelium. 
In  rare  eases  it  may  have  an  haematic 
origin.  At  the  same  time  nucleo- 
albiunin  should  be  sought  for  and  esti- 
mated in  proportion  to  the  amount  of  al- 
bumin whenever  its  presence  is  suspected. 
It  should  not  be  confounded  with  mucin, 
which  exists  in  very  small  quantities  in 
the  normal  urine.  Evano  (Gaz.  Heb.  de 
M6d.  et  de  Chir.,  Jan.  11,  1900). 

From  a  pathological  point  of  view  the 
causes  of  albuminuria  may  be  divided 
into  three  groups:  1.  Disturbances  of 
circulation.  2.  Changes  of  the  tubular 
epithelial  cells  or  of  the  walls  of  the 
blood-vessels  of  the  kidney.  3.  Changes 
in  the  composition  of  the  blood. 

1.  All  disorders  of  circiTlation  causing 
a  venous  renal  congestion  will  increase 
the  blood-pressure  in  the  capillaries  of 
the  kidney,  and  may  thus  give  rise  to  a 
transudation  of  albuminous  liquid;  when 


170 


ALBUMINURIA.    PHYSIOLOGICAL. 


the  congestion  is  very  great  the  urinary 
tubules  may  even  be  compressed  and  the 
escape  of  the  urine  rendered  difficult. 
When  this  is  the  case  and  when,  also, 
the  supply  of  arterial  blood  is  dimin- 
ished, the  tubular  epithelium  will  be 
damaged,  and  the  first  result  of  all  this 
is  albuminuria.  It  is  very  improbable 
that  arterial  congestion  ever  produces 
albuminuria,  although  the  experiments 
of  Mimk  and  Senator  tend  to  prove  the 
contrary. 

Functional  albuminuria  may  be  re- 
garded as  due  to  vascular  changes  and 
as  explainable  by  the  mechanical  theory. 
A  temporary  condition  of  anoxsemia, 
whether  due  to  either  arterial  or 
venous  obstruction,  induces  albuminuria, 
through  diminished  cell-activity  and 
vitality.  Results  of  experiments  per- 
formed upon  healthy  kidneys  prove  that 
albumin  is  secreted  by  epithelial  cells  of 
glomeruli,  in  capsule  of  Bowman,  and 
that  retardation  of  blood-current  through 
the  vascular  plexus  of  glomeruli  is  an 
essential  condition;  also  that  anoxaemia 
of  blood-current  of  the  tuft  causes  al- 
buminuria. J.  C.  Young  (Med.  Exam- 
iner, July,  '97). 

2.  Changes  of  the  tubular  epithelia 
and  the  walls  of  blood-vessels  of  the  kid- 
neys maj',  as  already  stated,  be  due  to 
disorders  of  circulation,  but  they  may 
also  be  caused  by  different  poisons  and 
toxins.  When  albuminuria  is  chiefly 
caused  by  degeneration  of  the  tubular 
epithelia,  their  protoplasm  dissolves  in 
the  urine,  and  nucleo-albumin  in  great 
quantity  is  contained  in  it,  combined 
with  serum-albumin  and  globulin. 

Urinalysis  of  400  cases  of  variola,  show- 
ing that  albuminuria  is  met  with  in  95 
per  cent,  of  cases,  32  per  cent,  having 
abundant  albumin.  The  albuminuria  is 
subject  to  marked  oscillations  in  amount, 
and  may  be  absent  on  certain  days.  The 
maximum  amount  is  usually  present  at 
the  beginning  of  the  febrile  period,  less 
commonly  during  suppuration  and  desic- 


cation. The  albumin  often  appears  in 
considerable  amount  when  solid  food  is 
first  taken  and  when  the  patient  is 
allowed  to  get  out  of  bed.  Albumin  was 
present  in  the  urine  in  75  per  cent,  of  the 
cases  during  convalescence,  usually  in 
very  small  amounts.  As  a  general  rule, 
there  was  abundant  albumin  in  the  se- 
vere eases.  There  is  no  such  thing  as  a 
distinctive  albuminuria  of  convalescence. 
The  albuminuria  is  due  to  a  lesion  of  the 
kidneys,  this  lesion  being  of  either  the 
interstitial  form  or  of  the  epithelial  form. 
Some  chronic  lesion  of  the  kidneys  prac- 
tically always  persists,  being,  however, 
extremely  slight,  as  a  rule,  and  causing 
practically  no  symptoms.  F.  Arnaud 
(Revue   de  MSd.,  May   10,  '98). 

Albuminuria  accompanying  litheemic 
attacks  can  only  be  due  to  irritation  or 
delicate  kidney-structures  of  child,  re- 
sulting from  attempt  at  elimination  from 
blood  of  poisonous  and  irritating  prod- 
ucts which  are  causes  of  lithsemie 
attacks.  Not  infrequently  small  quan- 
tity of  albumin  found  in  infants  and 
children  suffering  from  acute  lithsemic 
attacks.  Autointoxication  is  responsible 
for  this  albuminuria  either  in  early  or 
late  life.  In  middle  or  later  life  it  is  due 
to  arteriosclerosis  developed  by  this  au- 
tointoxication. Comparative  infrequency 
of  lithtemic  albuminuria  in  late  child- 
hood and  early  adult  life  is  due  to  better 
developed  and  more  resisting  structure 
of  kidney  and  to  the  fact  that  arterial 
changes  found  in  old  litliaemics  have  not 
yet  had  time  to  develop.  Rachford 
(Pediatrics,  July  1,  '98). 

Toxaemia  of  pregnancy  is  that  condi- 
tion which  occurs  as  the  result  of  pres- 
ence in  excess  of  toxic  material;  so  far 
as  is  known,  the  poison  is  of  the  nature 
of  an  alkaloid  or  alkaloids.  The  excre- 
tion of  waste-material  is  mainly  effected 
through  the  kidneys,  and  this  may  ac- 
count for  the  albuminuria  of  pregnancy, 
rather  than  mechanical  pressure  or  reflex 
spasm.  Kynoch  (Brit.  Med.  Jour.,  May 
21,  '98). 

Conclusions  of  previous  researches  on 
subject  of  albuminuria  during  preg- 
nancy: 1.  In  most  pregnant  Avomen  there 
is  a  certain  degree  of  autointoxication; 


ALBUMINURIA.    PHYSIOLOGICAL. 


171 


this  is  the  normal  toxseraia  of  pregnancy. 
2.  In  lesions  or  disease  of  the  kidney  or 
liver  the  toxic  condition  becomes  aggra- 
vated and  may  lead  to  grave  complica- 
tions, notably  urtemia.  3.  Toxaemia  of 
renal  origin  is  the  most  common,  asso- 
ciated with  albuminuria  and  oedema.  4. 
Albuminuria  is  not  the  cause  of  eclamp- 
sia, but  a  symptom  owning  a  common 
origin.  5.  Grave  complications — such  as 
coma,  dyspnoea,  and  paralysis  —  may 
prove  fatal  in  the  absence  of  eclampsia. 
6.  In  most  cases  toxic  eclampsia  breaks 
out  in  albuminuric  women;  albuminuria 
is  therefore  an  important  precursory  sign 
which  should  not  be  neglected.  7.  Per- 
sonal statistics  show  that  1  pregnant 
woman  in  40  is  albuminuric,  and  that,  of 
4  albuminurics,  1  develops  eclampsia; 
eclampsia  without  albuminuria  is  rare — 
1  case  in  9 — and  is  less  serious.  S.  Al- 
buminuria alone  without  eclampsia  has 
often  serious  or  fatal  consequences — in 
110  eases,  8  women  and  20  children 
died;  there  were  61  premature  labors, 
8  post-partum  heemorrhages,  and  3 
cases  of  threatened  convulsions.  9.  Al- 
buminuria should  be  looked  for  in  all 
pregnant  women.  10.  Every  albuminuric 
pregnant  woman  should  be  actively 
treated,  a  milk  diet  being  the  best.  11. 
In  ease  of  threatened  danger  premature 
labor  is  indicated,  and  gives  excellent 
results.  Charles  {.Jour.  d'Accouche- 
ments,  Apr.  3,  '98). 

By  many  the  malarial  poison  is  re- 
garded as  an  efficient  cause  of  chronic 
nephritis.  Out  of  a  series  of  712  cases  of 
malaria  studied  personally,  only  3  were 
found  suffering  from  chronic  nephritis; 
and  in  2  out  of  these  it  was  probable 
that  the  renal  affection  was  due  to 
causes  other  than  malaria.  It  would 
thus  seem  that  malarial  fever  cannot  be 
regarded  as  a  cause  of  nephritis  in  the 
sense  that  scarlatina,  diphtheria,  etc., 
are.  J.  H.  Brownlow  (Amer.  Med. 
Times,  Mar.,  1900). 

Case  in  a  man,  aged  41,  suffering  from 
an  acute  articular  rheumatism,  with  a 
mitral  systolic  murmur,  the  urine  con- 
taining albumin  and  casts.  Under  the 
usual  treatment  he  recovered  in  three 
weeks.  Four  recurrences  were  attended 
by  albuminuria,  the  amount  of  the  albu- 


min decreasing  with  the  decline  of  the 
iheumatic  symptoms.  The  heart  com- 
plication was  only  temporary.  The 
articular  symptoms,  the  pyrexia,  and 
the  renal  attack  thus  constituted  a 
rheumatic  symptom-complex.  The  renal 
cells  had  probably  been  affected  by  rheu- 
matic toxins.  Parkes  Weber  (Ed.  Med. 
Jour.,  Jan.,  p.  48,  1900). 

The  alterations  in  the  blood  which 
produce  the  albuminuria  and  the  ascites 
are  due  to  the  presence  of  toxins  which 
are  derived  from  the  gastro-intestinal 
tract.  This  fact  has  been  demonstrated 
beyond  all  doubt  experimentally  by  Do- 
minicis.  In  man  intestinal  antiseptics 
will  cure  such  cases,  and  cause  the  albu- 
minuria and  the  ascites  to  disappear. 
If  the  treatment  is  suspended  for  a  time, 
and  the  patient  allowed  to  eat  beyond 
his  digestive  powers,  these  phenomena 
soon  reappear.  Three  cases  in  which 
the  above  conditions  were  noted.  G.  K. 
Filocamo  (Gaz.  Inter,  di  Med.  Pratica, 
Mar.  31,  1900). 

3.  When  the  composition  of  the  blood 
is  altered  the  urine,  very  often,  will  be 
albuminous.  This  can  be  proved  ex- 
perimentally by  injecting  egg-albumin, 
soluble  casein,  haemoglobin,  etc.,  into 
the  veins  of  animals,  for  generally  the 
quantity  of  albumin  excreted  after  the 
injection  will  exceed  the  injected  quan- 
tity. Similar  results  may  be  obtained  by 
the  injection  of  pepton  and  propepton, 
whereas  the  albuminates  are  generally 
inoffensive.  Ingestion  of  a  very  large 
quantity  of  egg-albumin  is  liable  to 
provoke  albuminuria. 

Fifty-five  cases  of  nephritis,  either 
chronic  or  subacute,  with  albuminuria, 
in  which  the  haemoglobin  and  specific 
gravity  of  blood  and  amxDunt  of  albumin 
excreted  in  urine  per  day  were  esti- 
mated. There  is  more  or  less  constant 
relation  between  the  degree  of  hydrsemia 
and  the  amount  of  albumin  excreted. 
The  blood  of  women  is,  on  an  average, 
about  2.12  lower  in  specific  gravity  than 
the  blood  of  men.  The  hydr^^mia  bears 
no  relation  to  the  haemoglobin,  but 
varies  inversely  as  the  specific  gravity 


172 


ALBUMINURIA.    PHYSIOLOGICAL. 


of  the  blood.     No  definite  relation  ap- 
pears to  exist  between  the  hydraemia  and 
the   dropsy;    but   it   seems   as   if   there 
must   be    some    etiological   relation   be- 
tween the  albuminuria  and  the  hydras- 
mia.     Geza  Dieballa  and  Ladislaus  von 
Ketly  (Deut.  Archiv  f.  klin.  Med.,  Sept. 
6,  '98). 
Semmola  has  tried  to  prove  that  albu- 
minuria is  always  caused  by  changes  of 
the    blood    characterized    by    abnormal 
diffusibility  of  its  proteids,  and,  in  his 
opinion,  the  pathological  changes  in  the 
kidneys  are  consecutive  to  the  albumi- 
nuria.    Though  his  theory  is  not  gener- 
ally accepted,  Eosenbach  has  adopted  it 
for  the  albuminuria  which  is  not  caused 
by  nephritis,  and  regards  it  in  such  cases 
as  a  salutary  and  regulating  process. 

In  most  clinical  cases  different  causes 
are  simultaneously  in  action,  and  it  is 
generally  very  difficult  to  determine 
which  is  the  preponderating  etiological 
factor. 

Although  albumin  is  not  recognized 
as  a  normal  constituent  of  the  urine,  it 
is,   nevertheless,   a  fact   that   traces   of 
albumin,  and  even  a  rather  considerable 
amount  of  it,  may  be  found  in  the  urine 
of  persons  otherwise  healthy  and   pre- 
senting no  symptoms  of  disease  of  the 
kidneys  or  of  the  organs  of  circulation. 
Case    of    intense,    continuous    albumi- 
nuria of  seven  yaers'  duration  in  an  ap- 
parently healthy  man,  67  years  of  age, 
who,   seven    years   before,   because    of   a 
little   disturbance  of  appetite,   had   con- 
sulted a  physician,  of  whom  he  learned 
that  his  urine  contained  both  sugar  and 
albumin.    There  was  no  hereditary  taint, 
no    previous    illness,    no    alcoholism    or 
syphilis,  that  could  in  any  way  account 
for  the  urinary  findings.    The  most  care- 
ful examination  failed  to  reveal  any  le- 
sion in  any  organ.    Dieulafoy,  who  exam- 
ined the  patient,  did  not  look  upon  the 
case  as  one  of  Bright's  disease,  but  as  a 
sort  of  diabetic  albuminuria  which  can 
be  regarded  as  an  exaggeration  of  physi- 
ological   albuminuria.      M.    de    Cresan- 


tignes    (.Jour,  de  Med.  de  Paris,  p.  125, 
'96). 

Albuminuria  after  exercise.  Specimens 
of  urine  from  108  soldiers  examined. 
Albumin  was  present  in  41.73  per  cent, 
of  specimens  of  urine  taken  before  drill, 
and  in  63.23  per  cent,  of  cases  after  it. 
Levison  (St.  Barth.  Hosp.  Rep.,  xxxv, 
169,  '99). 

Albuminuria  after  exertion.  Urine  of 
9  members  of  the  Rugby  foot-ball  team 
examined  after  playing  in  the  final  cup 
tie.  In  every  instance  albumin  was  pres- 
ent, and  in  some  cases  hyaline  casts  also. 
Herbert  Hawkins  (Brit.  Med.  Jour.,  ii, 
1598,  '99). 

Albumin  in  the  urine  after  severe  exer- 
cise. Eighty-three  specimens  of  urine 
taken  from  oarsmen  at  Harvard  Uni- 
versity, when  in  training  for  races,  and 
examined  for  albumin.  Of  these,  48  con- 
tained albumin.  After  time-rows  and 
races  the  urine  was  invariably  albumi- 
nous. Darling  (Boston  Med.  and  Surg. 
Jour.,  cxli,  205,  '99). 

Cyclical  albuminuria  has  been  ascribed 
by  Stirling  to  the  sudden  shock  of  the 
kidneys  from  the  pressure  of  blood  upon 
assuming  the  upright  position  on  arising. 
The  shock  from  sudden  rising  plays  but 
slight,  if  any,  role.  Even  when  the  up- 
right position  is  assumed  very  slowly, 
albumin  appears  in  the  urine  in  such 
cases.  The  kidneys  are  merely  unable  to 
stand  the  increase  of  pressure  that 
occurs  with  the  upright  position. 

Cyclical  albuminuria  is  not  necessarily 
related  to  gout.  There  is  also  no  evi- 
dence that  cyclical  albuminuria  is  due  to 
a  slight  nephritis  resulting  from  a  previ- 
ous attack  of  acute  nephritis.  It  is  a 
form  of  albuminuria  from  venous  stagna- 
tion, the  result  of  previous  inflammation 
of  the  kidneys  and  lack  of  elasticity  of 
the  vessel-walls  of  the  glomeruli.  Ru- 
dolph (Centralb.  f.  innere  Med.,  Feb.  24, 
1900). 

Albuminuria  following  renal  palpation. 
Renal  hsematuria  with  albuminuria  noted 
in  several  cases  in  which  the  kidney  had 
been  examined  bimanually  and  in  which 
no  albumin  had  been  present  in  the  urine 
before  examination.  The  pressure  to 
which  the  kidney  is  exposed  causes  cir- 
culatory   changes   which    permit   of   the 


ALBUMINURIA.    LIFE-INSURANCE. 


173 


transudation   of   serum   from   the   renal 

capillaries.     C.  Menge   (Miinchener  metl. 

Woch.,  June  5,  1900) . 

Many  clinicians  therefore  admit  that 

albuminuria  may  be  regarded,  in  some 

cases,  as  physiological;   this  is,  however, 

contested  by  as  many. 

Virehow  described  a  physiological  al- 
buminuria in  infants,  occurring  in  the 
first  days  of  life,  and  explained  it  by  the 
sudden  changes  of  circulation  taking 
place  immediately  after  delivery. 

The  children  of  mothers  suffering  from 
eclampsia   or   chronic   albuminuria   may 
show  this  condition  from  birth.     In   10 
children  whose  mothers  were  non-albu- 
minuric  1  only  showed  traces  of  albumin, 
while  in  4  whose  mothers  were  eclamptic 
3  showed  albuminuria,  while  the  mother 
of   the    fourth    was   only    very    slightly 
affected.      Albuminuria    may    thus    be 
transmitted  from  the  mother  to  the  child, 
and  this  condition  in  the  child  may  be 
prolonged    considerably    over    early    in- 
fantile life,  probably  preparing  the  way 
for   future   attacks   of   nephritis   in   the 
course  of  the  ordinary  diseases  of  child- 
hood.     Many    cases    of    so-called    albu- 
minuria  may  be   hereditary.     Should   a 
mother  be  known  to  suffer   from  albu- 
minuria, the  children  should  be  carefully 
examined,  and  every  effort  made  to  pre- 
vent the  occurrence  of  scarlet  fever  or 
other  febrile  disorders.     Fieux  (Jour,  de 
M6d.,  July  25,  '99). 
Fleusburg  and  Sjoquist  have  recently 
proved   that   albuminuria  regularly   oc- 
curs in  the  first  days  of  life,  and  that 
the  urine  also  contains  an  extraordinary 
quantity  of  itric-acid  crystals;    probably 
the   albuminuria   is   then   owed   to   the 
irritation  of  the  kidneys  caused  by  these 
crystals.      Ebstein    and    Nicolaier   have 
experimentally    shown   that,    when    the 
kidneys  are  forced  to  excrete  a  surplus 
of  uric  acid  which  cannot  be  dissolved, 
but  goes  to  the  bottom  in  the  form  of 
crystals,  the  urine  commonly  contains 
albumin  and  sometimes  even  blood. 
Gull  found  a  certain  form  of  physio- 


logical albuminuria  in  adolescents  about 
the  age  of  puberty,  especially  in  weak 
and  pale  individuals.  Other  authors, 
among  whom  is  Quain,  have  noticed  that 
this  condition  is  frequently  associated 
with  masturbation. 

Slight  traces  of  albumin  met  with  ex- 
tremely commonly,  especially  betweeft 
the  ages  of  18  and  25  years.  The  urine 
found  to  be  albuminous  in  45.5  per  cent, 
of  129  hospital  patients  between  these 
ages.  Levison  (St.  Earth.  Hosp.  Rep., 
xxxv,  169,  '99). 

Physiological  Albuminuria  and  Life- 
insurance. — The  question  of  physiolog- 
ical albuminuria  in  adults  has  been  much 
disciissed  during  the  past  few  years  and 
has  particularly  engaged  the  interest  of 
the  medical  men  employed  in  insurance- 
work. 

Statistics  of  life-insurance,  etc.,  show- 
ing that  physiological  albuminuria  is 
met  with  in  America  in  2  per  cent.;  in 
England  in  3  per  cent.  Privations, 
scanty  food  and  clothing,  unsanitary 
surroundings,  cold  bathing,  severe  phys- 
ical exercise,  and  mental  strain  fre- 
quently give  rise  to  albuminuria.  Shep- 
herd (New  Eng.  Med.  Monthly,  '89). 

Albuminuria,  natural  or  artificial, 
never  occurs  except  as  the  result  of 
pathological  changes  in  the  kidney,  and 
is  consequently  never  normal  or  physio- 
logical, and  is  never  to  be  regarded  with- 
out distrust.  Millard  (N.  Y.  Med.  Jour., 
May  9,  '91). 

Instance  where  a  special  examination 
of  a  case  was  referred  to  author  by  the 
medical  officers  of  a  prominent  life-insur- 
ance company  with  a  mere  trace  of  albu- 
min in  the  urine.  He  sought  and  found 
other  evidence  of  a  renal  involvement, 
and  advised  strongly  against  the  risk; 
another  company  accepted  the  risk  for 
$10,000,  and,  before  the  second  annual 
premium,  the  patient  died.  Purdy  (N.  Y. 
Med.  Jour.,  Feb.  28,  '91). 

There  is  at  present  a  tendency  to  un- 
derrate the  importance  of  albuminuria 
in  life-assurance.  While  the  possibility 
of  ephemeral  and  unimportant  attacks  in 


174 


ALBUMINURIA.     LIFE-INSURANCE. 


adolescents  is  undoubted,  the  presence 
of  albuminuria  in  persons  of  over  forty 
years  is  vei-y  significant.  F.  de  Haviland 
Hall  (Brit.  Med.  Jour.,  Feb.  20,  '93). 

The  presence  of  albumin  in  persons 
over  middle  age  of  exceeding  importance, 
especially  the  variety  of  albuminuria  in 
■which,  with  a  low  specific  gravit.y,  the 
quantity  of  albumin  present  is  only  to 
be  perceived  with  the  greatest  care.  This 
form  is  indicative  of  gout  of  the  kidney : 
a  form  in  which  the  disease  might  ad- 
vance to  such  an  extent  as  to  threaten 
the  life  of  the  patient,  though  the  merest 
trace  of  albumin  might  be  present  in  the 
urine.  If  properly  treated  with  a  non- 
nitrogenous  diet  and  warmth  to  the  sur- 
face, these  cases  might  go  on  for  j'ears. 
Lauder  Brunton  (British  Med.  Jour., 
Feb.  20,  '93). 

It  is  necessary,  especially  in  women,  to 
take  steps  to  ascertain  that  the  albumin 
in  the  urine  is  not  of  extravesical  origin. 
One  frequent  cause  of  the  presence  of 
albumin  in  the  urine  of  females  is 
hsemorrhagic  endometritis.  Routh  (Brit. 
Med.  Jour.,  Feb.  20,  '93). 

Necessity  of  having  the  patient  urin- 
ate in  the  presence  of  the  examiner,  in 
order  to  prevent  the  substitution  of 
other  urine.  Mackenzie  (London  Lan- 
cet, June  16,  '94). 

Quite  young  subjects  who  have  albu- 
minuria should  be  considered  as  below 
the  average.  Douglas  Powell  (London 
Lancet,  June  16,  '94). 

Albuminuria  is  not  always  patholog- 
ical; andj  if  albumin  be  not  found  at 
the  second  or  third  examination,  the 
case  should  be  recommended  for  accept- 
ance. Symes  Thompson  (London  Lan- 
cet, June  16,  '94). 

In  cyclical  albuminuria  the  prognosis 
is  generally  admitted  to  be  good,  al- 
though it  is  commonly  assumed  that  the 
kidneys  in  such  eases  are  specially  vul- 
nerable. If  this  be  so,  it  is  remarkable 
that  the  occurrence  of  fevers,  even  scar- 
let fever,  does  not  produce  a  notable 
increase  in  the  amount  of  albumin.  The 
contrary  may,  in  fact,  occur,  as  in  one 
of  Keller's  cases,  in  which  the  amount  of 
albumin  was  actually  diminished  during 
an  attack  of  scarlet  fever,  the  favorable 


influence  of  rest  in  the  recumbent  atti- 
tude more  than  counterbalancing  the  un- 
favorable influence  of  the  febrile  attack. 
Editoi-ial   (Practitioner,  June,  '97). 

Phj'siological  albuminuria  believed  to 
be  due  to  ingestion  of  a  greater  amount 
of  albumin  than  the  individual  can  per- 
fectly oxidize,  result  being  excretion  of 
albiunin.  The  habit  of  overeating  is 
usually  associated  with  this  condition. 
W.  H.  Porter  (Columbia  Med.  Jour.,  vol. 
XX,  No.  4,  '98). 

The  mass  of  evidence  which  has  come 
to  us  of  late  from  the  autopsy-table 
shows  conclusively  that  chronic  nephritis 
exists  and  is  an  unrecognized  cause  of 
death  in  a  proportion  of  cases  far  beyond 
ordinary  belief,  and  the  comparison  of 
carefully  kept  records  of  cases  before 
death  with  autopsy  findings  shows  that 
little  reliance  can  be  placed  on  the  mere 
urinary  examination,  either  positive  or 
negative,  as  a  means  of  absolute  diag- 
nosis or  prognosis  of  Bright's  disease. 
The  writer's  own  experience  leads  him 
to  believe  that  (1)  Bright's  disease  may 
exist  without  the  ordinary  urinary 
manifestations, — viz.,  albumin  or  casts: 
(2)  albumin  and  casts  may  be  found  in 
the  normal  urine  and  do  not  necessarily 
mean  Bright's  disease;  (3)  given  a  case 
of  chronic  Bright's  disease  with  albu- 
minuria, the  fact  of  its  presence,  its  con- 
stancy, or  its  amount  has  absolutely  no 
prognostic  significance.  C.  A.  Tuttle 
(Jour.  Amer.  Med.  Assoc,  Mar.  31,  1900). 

Series  of  experiments  show  that  the 
albumin  present  in  nephritic  urine  is 
derived  from  the  blood  and  is  different 
from  the  specific  kidney  albumins.  L. 
Aschoff  (Lancet,  Sept.  6,  1902). 

It  is  characteristic  of  physiological 
albuminuria  that  the  quantity  of  albu- 
min is  generally  small  and  that  the  ex- 
cretion is,  in  most  cases,  intermittent, 
or  cyclical.  Leube,  Pavy,  Fiirbringer, 
Klemperer,  and  many  other  authors  have 
studied  this  condition. 

Pavy  introduced  the  denomination 
"cyclical  albuminuria"  for  the  cases  in 
which  the  albuminuria  ceases  and  re- 
turns at  regular  intervals. 


ALBUMINURIA.    LIFE-INSURANCE. 


175 


Case  of  a  clilorotie  girl,  15  years  old, 
in  whom  albuminuria  was  of  the  cyclical 
type:  albumin  appeared  about  11  a.m., 
and  reached  a  maximum  about  3  o'clock 
in  the  afternoon,  diminishing  thereafter 
until  it  disappeared  completely  by  8 
o'clock  p.ic,  and  remaining  absent  dur- 
ing the  night.  Recalling  an  observation 
of  Heubner's,  who  found  cyclical  albu- 
minuria in  several  members  of  the  same 
family,  the  author  examined  the  urine 
of  two  sisters  and  two  brothers  of  the 
patient  and  found  the  same  condition  in 
one  of  the  sisters,  a  girl  of  13  years,  also 
chlorotic.  Treatment  of  the  chlorosis 
had  no  effect  upon  the  albuminuria. 
Schon  (Jahrbuch  f.  Kinderh.,  B.  41,  S. 
307,  '96). 

Pavy  likewise  insists  upon  posture  as 
the  invariable  cause  of  cyclical,  or  in- 
termittent, albuminuria,  the  excretion 
ceasing  when  the  subject  is  in  the  re- 
cumbent position  and  going  on  only 
■when  he  is  walking  or  standing.  The 
cycles  are  commonly  completed  within 
the  day,  but  in  a  case  narrated  by  Klem- 
perer  there  were  two  cycles,  the  maxi- 
mum of  albuminuria  taking  place  in  the 
forenoon  and  afternoon. 

Effect  of  rest  in  bed:  in  one  case,  in  a 
girl  8  years  of  age,  of  wasting  and  loss 
of  appetite,  the  average  daily  amount  of 
albumin  passed  for  five  days,  while  the 
child  was  running  about,  was  51  centi- 
grammes. She  was  then  kept  in  bed  for 
five  days,  and  the  average  daily  amount 
of  albumin  sank  to  4  centigrammes;  in 
the  next  five  days,  during  which  she  was 
running  about  again,  the  average  daily 
amount  of  albumin  rose  to  36  centi- 
grammes. The  fall  on  going  to  bed  and 
the  rise  on  getting  up  were  immediate. 
The  proteids  present  in  the  urine  in 
these  cases  are  serum-albumin,  serum- 
globulin,  and  nucleo-albumin.  Keller 
(.Jahrb.  f.  Kinderh.,  B.  41,  p.  356). 

In  many  instances  bicycling  gives  rise 
to  an  albuminuria  that  cannot  be  dis- 
tinguished with  the  microscope  from  that 
of  genuine  kidney  disease,  but  one  that 
must  be  looked  upon  as  physiological, 
since  it  disappeared  within  a  few  days 


after  cessation  of  the  exertion,  leaving 
absolutely  no  signs  of  disease.  Observa- 
tions made  on  twelve  bicyclists,  eight  of 
whom  were  trained  and  four  untrained. 
Among  the  eight  trained  wheelmen  there 
was  only  one  whose  urine  contained  al- 
bumin before  the  exercise,  but  after  it 
the  urine  was  albuminous  in  seven.  In 
six  of  them,  including  the  one  whose 
urine  was  free  from  albumin,  there  were 
at  the  same  time  present  in  the  urine 
easts  in  numbers  as  great  as  are  gener- 
ally met  with  in  acute  or  chronic  paren- 
chymatous nephritis;  and  the  two  others 
had  a  few  hyaline  casts.  Most  of  the 
casts  were  hyaline ;  the  minority  showed 
distinct  renal  epithelia  and  were  granu- 
lar. Free  renal  epithelia  were  found  in 
every  instance.  White  blood-corpuscles 
appeared  sparingly,  but  red  corpuscles 
were  not  met  with  at  all.  Among  the 
four  untrained  wheelmen,  in  all  of  whom 
the  urine  was  free  from  albumin  before 
the  exercise,  two  showed  albuminuria 
and  one  cylindruria  after  riding  from  an 
hour  and  a  half  to  three  hours.  Mueller 
(Miinchener  med.  Woch.,  No.  48,  '96). 

Three  cases  of  intermittent  albumi- 
nuria which  occurred  in  the  same  family. 
As  often  as  six  times,  based  upon  as 
many  observations,  attention  has  been 
called  to  the  family  character  of  this 
disease.  In  the  family  of  the  children 
mentioned  above  gout  is  hereditary :  a 
very  important  fact  as  regards  the  eti- 
ology of  the  disease.  Lacour  (Lyon 
Med.,  No.  25,  '97). 

Albuminuria,  particularly  cyclical  or 
irregular  albuminuria,  may  be  frequently 
due  to  gastro-intestinal  autointoxication. 
Case  in  which  hydatid  cysts  of  the  liver 
caused  marked  constipation  and  icterus 
and  distinct  albuminuria;  latter  disap- 
peared after  operation  upon  the  cysts  and 
recovery  from  disturbed  condition  of  di- 
gestive organs.  The  function  of  the  liver 
and  of  thyroid  gland  is  particularly  im- 
portant in  such  albuminuria,  since  dis- 
turbance of  either  organ  may  lead  to 
production  of  toxic  substances  which 
cause  albuminuria.  A.  Praetorias  (Ber- 
liner klin.  Woch.,  Apr.  4,  11,  '98). 

The  diagnosis  of  physiological  albu- 
minuria ought  not  to  be  made  except  in 


176 


ALBUMINURIA.    LIFE-INSURANCE. 


eases  when  persons  presenting  no  other 
symptom  of  disease  excrete,  constantly 
or  intermittently,  a  urine  containing  a 
scanty  quantity  of  albumin,  but  no 
morphotic  elements  and  especially  no 
casts.  The  centrifugal  apparatus,  now 
coming  into  general  use,  will  certainly 
contribute  to  restrain  the  number  of 
these  cases. 

Even  when  no  casts  can  be  found, 
albuminuria  ought  never  be  regarded 
.as  absolutely  inoffensive.  Although  a 
cyclical  albuminuria  continuing  years 
may  be  compatible  with  perfect  health, 
:still  many  authors  (Johnson,  Greenfield, 
Bull,  etc.)  are  of  the  opinion  that  it  sig- 
nifies the  first  stage  of  the  evolution  of 
granular  atrophy  of  the  kidneys.  The 
albuminuria  often  found  in  parturient 
women  (Aufrecht  saw  it  in  56  per  cent, 
■of  all  cases)  must  also  be  regarded  as 
physiological. 

Protest  against  the  indiscriminate  re- 
jection of  candidates  foi'  assurance  on 
account  of  albuminuria:  that  is,  after 
a  merely  chemical  examination  of  the 
urine.  In  every  case  in  which  albumin 
is  found  microscopical  examination  of 
the  sediment  obtained  by  centrifugali- 
zation  is  essential  for  the  avoidance  of 
unnecessary  rejections.  There  are  two 
fundamentallj'  distinct  forms  of  albu- 
minuria, the  renal  and  the  extrarenal. 
The  latter  is  indicative  merely  of  a 
functional  or  organic  lesion  of  the  gen- 
ito-renal  tract,  which  is  not  necessarily 
or  even  usually  dangerous  to  life.  Ex- 
trarenal albumiuuria  is  characterized  by 
its  transitory  and  intermittent  nature. 
Since,  however,  some  forms  of  renal 
albuminuria  are  equally  transitory  and 
intermittent,  the  final  distinction  be- 
tween the  two  is  based  on  the  micro- 
scopical examination  of  the  sediment. 
The  presence  of  blood,  pus-cells,  epi- 
thelium from  the  mucosa  of  the  urinarj' 
tract,  spermatozoa,  and  shreds  of  mucus, 
in  the  absence  of  renal  elements,  is 
decisive  of  an  extrarenal  origin.  Prob- 
ably in  many  cases  of  so-called  physi- 
ological  albuminuria   the    origin   of   the 


albumin  is  extrarenal.  Zeehnisen  found 
albumin  in  the  urine  of  21  out  of  144 
ophthalmic  patients;  in  60  per  cent,  the 
presence  of  blood,  vesical  or  urethral 
epithelium,  pus,  or  spermatozoa  pointed 
to  an  extrarenal  origin.  Von  Noorden 
found  albumin  in  the  urine  of  154  ap- 
parently healthy  soldiers,  which  in  106 
originated  extrarenally.  Flensburg  ex- 
amined the  urine  of  those  soldiers  in 
which  he  had  unexpectedly  found  albu- 
min at  the  end  of  their  two  years' 
service;  in  the  majority  every  trace  of 
albumin  had  disappeared,  and  in  the 
remainder  there  was  no  single  symptom 
of  nephritis.  In  every  case  of  albumi- 
nuiia  the  presence  of  blood  should  be 
excluded,  for  traces  of  blood  too  minute 
to  be  detected  by  Heller's  or  the  spectro- 
scopic test  will  nevertheless  give  the 
reactions  of  albumin.  In  extrarenal  al- 
buminuria nucleo-albumins  preponder- 
ate. In  doubtful  cases  the  urine  should 
be  obtainea  by  catheterism,  so  that 
every  source  of  contamination  may  be 
avoided.  Albuminuria  of  renal  origin 
may  be  either  temporary  or  permanent, 
functional  or  organic.  Organic  lesions 
are  characterized  by  persistence.  But 
persistence  is  not  an  absolute  bar  to 
acceptance,  for  eases  occur,  though 
rarely,  in  which  albvuuinuria  with  renal 
casts  continues  indefinitely  without  any 
disturbance  of  health.  If,  however, 
there  are  polyuria,  casts,  cardiac  hyper- 
trophy, or  dilatation,  arteriosclerosis, 
retinitis,  urtemia,  and  oedema,  nephritis 
is  obviously  present.  Every  case  should 
be  judged  on  its  merits.  Even  without 
albuminuria,  endarteritis,  or  any  one  of 
the  above-mentioned  symptoms,  com- 
bined with  persistently-increased  diu- 
i-esis  and  a  specific  gravity  between  1.010 
and  1.012,  is  extremely  suggestive  of  an 
organic  renal  lesion.  The  functional 
form  of  renal  albuminuria  is  transitory 
or  intermittent,  and  is  principally  due 
to  intoxication  or  autointoxication. 
The  toxie  symptoms  produced  must  de- 
cide in  each  case  Avhether  the  applicant 
should  be  accepted.  The  most  impor- 
tant variety  is  that  which  occurs  after 
exercise,  and  which  points  to  a  meta- 
bolic instability  which  may  possibly  be- 
come dangerous.  Renal  albuminuria 
which     persists     during     convalescence 


ALBUMINURIA.     PATHOLOGICAL. 


177 


from  infectious  diseases  is  of  no  more 
significance  as  a  sequel  than  slight  bron- 
chitis; if  there  are  no  cardiovascular 
changes  the  candidate  may  be  passed. 
Some  of  the  most  difficult  problems  are 
connected  with  cases  of  ascending  infec- 
tion from  the  bladder.  If  the  process 
is  tuberculous,  the  candidate  should 
clearlj'  be  rejected.  In  other  cases  the 
question  whether  the  kidney  is  involved 
will  be  decided  by  the  effect  produced 
and  the  condition  of  the  heart  and  ar- 
teries. Many  eases  of  functional  al- 
buminuria are  due  to  circulatory  dis- 
turbances. Of  this  nature  is  probably 
that  form  known  as  "cyclical,"  or  "pos- 
tural," in  which  there  is  usually  some 
circulatory  disturbance,  as  evidenced  by 
cardiac  dilatation,  tachycardia,  palpita- 
tion, or  anfemia,  though  doubtless  hered- 
ity and  other  factors  are  involved.  It 
is  the  rule  to  reject  these  applicants ; 
but,  as  the  prognosis  is  usually  excel- 
lent, there  is  no  reason  why  they  should 
not  be  accepted  after  a  period  of  pro- 
bation. This  form  of  albuminuria  is 
practically  identical  with  the  albumi- 
nuria of  cardiac  disease.  Stokvis  (Brit. 
Med.  Jour.;  from  Wiener  med.  Woch., 
May  3  and  10,  1902). 

Pathological  Albuminuria.  —  Patho- 
logical albuminuria  is  found  in  patho- 
logical changes  of  the  blood — as  ana- 
mia,  leukffimia,  pseudoleitkasmia,  scurvy, 
icterus,  and  diabetes — even  when  the 
kidneys  do  not  present  pathological 
changes. 

It  is  also  found  in  many  disorders  of 
the  nervous  system,  as  epilepsy,  mi- 
graine, psychosis  apoplexy,  neurasthenia, 
and  Basedow's  disease,  etc.  Delirium 
tremens  has  also  been  mentioned  as  a 
nervous  disease  often  complicated  with 
albuminuria. 

Delirium  tremens  is  alwaj-s  accom- 
panied by  fever  and  is  probably  provoked 
by  a  microbic  toxin  or  an  autointoxica- 
tion. Jacobson  (Hospitalstidende,  p.  193, 
'97). 

Although  the  kidneys,  theoretically, 
are  believed  to  be  healthy  in  the  diseases 


mentioned  above,  there  is  no  doubt  that 
albuminuria,  in  many  cases  of  this  class, 
is  caused  by  pathological  changes  of  the 
kidneys. 

In  all  febrile  and  especially  in  all  in- 
fectious diseases  albuminuria  is  a  very 
frequent  symptom.  It  has  been  noticed 
in  enteric  fever,  diphtheria,  variola,  after 
vaccination,  in  erysipelas,  influenza, 
rheumatic  fever,  etc.  In  these  cases  the 
albuminuria  is  caused  by  changes  in  the 
composition  of  the  blood,  increase  of 
blood-pressure,  rise  of  temperature,  and 
finally  by  changes  in  the  structure  of 
the  kidneys,  especially  of  the  tubular 
epithelial  cells. 

Albuminuria  has  been  observed  in 
diseases  of  the  intestines,  dilatation  of 
the  stomach,  ileus,  ruptures,  etc.,  and 
in  renal  venous  congestion  caused  com- 
monly by  disease  of  the  heart  or  the 
great  vessels. 

Albuminuria  may  be  produced  by  in- 
testinal disorders  in  children;  may  be 
due  to  the  injurious  action  on  the  renal 
epithelium  of  the  toxic  products  of  ab- 
normal fermentations.  Jacobi  (N.  Y. 
Med.  Jour.,  .Jan.  IS,  '96). 

It  is  present  in  all  diseases  of  the 
kidneys.  Acute  as  well  as  chronic  albu- 
minuria is  generally  found,  whether  the 
diffuse  form  of  nephritis  or  as  circum- 
scribed diseases — such  as  infaretus,  ab- 
scesses, or  tumors — ^be  present.  After 
retention  of  urine  the  portion  of  urine 
first  passed  is  frequently  albuminous. 

Certain  remedies  may  also  give  rise  to 
albuminuria. 

Case  of  a  syphilitic  subject  who,  after 
antisyphilitic  treatment  with  4  '/^  ounces 
of  mercurial  ointment  and  the  iodide  of 
potash,  developed  osdema  of  the  lower 
extremities,  and  8  per  cent,  albumin  in 
the  wine.  Another  attempt  at  treat- 
ment by  inunction  caused  the  albumin 
to  increase  to  the  enormous  quantity  of 


178 


ALBUMINURIA.     TESTS. 


60  per  cent.;  after  discontinuing  it  he 
slowly  recovered,  ivhile  the  albumin  de- 
creased decidedly  in  amount.  Saalfeld 
{Deutsche  med.-Zeitung,  No.  1,  '95). 

Chlorate  of  potash,  which  is  often  used 
to  prevent  mercurial  stomatitis,  is  fre- 
quently the  cause  of  the  appearance  of 
albumin  in  the  urine.  Case  of  a  young 
physician  who  died  after  employing  small 
quantities  of  this  drug  in  a  mouth-wash. 
Acute  poisoning  by  this  drug  is  easily 
recognized  by  the  large  quantity  of  al- 
bumin and  blood  in  the  urine.  Mankie- 
wicz  (Deutsche  med.-Zeitung,  No.  1,  '95). 
Case  in  which  albuminuria  and  uraemia 
were  apparently  produced  by  the  applica- 
tion of  a  blister.  Huchard  (Eevue  de 
Th6r.  Medico-Chir.,  Apr.,  '96). 

Examination    of    8000    specimens    of 
urine  derived   from   201   syphilitic  men, 
79  syphilitic  females,  and  35  persons  who 
were  not  syphilitic.    Albuminuria  found 
in   25   of   the   men,   and   in   the   women 
marked  albuminuria  in  4  cases.     In  35 
cases   of  bubo,  the  urine  of  which   was 
examined  363  times,  a  trace  of  albumin 
was  only  found  on  2  or  3  occasions.    The 
administration    of   mercury    in   no    case 
gave  rise  to  very   marked  albuminuria. 
Lewin,  who  has  used  hypodermic  injec- 
tions 80,000   times   with   sublimate,   has 
never   seen    nephritis   result.      It   seems 
evident  that  the  bichloride  is  the  prefer- 
able  preparation   for   hypodermic   injec- 
tions.     Julius   Heller    (Schmidt's    Jahr- 
biieher.  No.  1,  '97). 
The  prognosis  and  treatment  of  albu- 
minuria, therefore,  depends  entirely  on 
the   origin   and   causes   of   it,   and   the 
reader  is  referred  to  the  various  diseases 
in  which  it  occurs  as  a  sj'mptom. 

Tests.  — •  By  means  of  the  tests  com- 
monly employed  the  presence  of  albu- 
min in  the  urine  is  revealed,  but  no 
attempt  is  made  to  discern  between  the 
different  proteids;  the  differential  diag- 
nosis between  the  serum-albumin,  glob- 
ulin, etc.,  will  be  given  later  on. 

The  sample  of  iirine  to  be  examined 
must  be  very  limpid  without  deposits  of 
any  kind;  if  this  be  not  the  case,  the 
urine  should  be  filtered  previous  to  the 


examination,  because  a  slight  cloud  of 
coagulated  albumin  will  only  be  discern- 
ible when  the  fluid  is  very  clear  before 
the  reagent  has  been  added.  When  the 
urine  contains  many  bacteria,  even  re- 
peated filtration  will  be  insufficient  to 
make  it  clear;  this  can  then  be  done, 
however,  by  addition  of  a  solution  of 
sulphate  of  magnesia  and  of  carbonate 
of  soda.  By  shaking  the  mixture  a 
precipitate  of  carbonate  of  magnesia  is 
formed,  and  when  this  is  removed  by 
filtration  the  filtrate  will  be  perfectly 
clear.  In  many  cases  a  few  drops  of 
caustic  soda  will  clear  the  urine,  but 
urine  treated  in  this  manner  will  not 
give  a  precipitate  of  albiimin  by  boiling, 
while  the  test  of  Heller  is  practicable 
also  in  this  ease. 

Test  by  Boiling. — A  few  cubic  cen- 
timetres of  urine  are  heated  to  the  boil- 
ing-point and  some  (5  to  10)  drops  of 
nitric  acid  added.  When  the  urine  is 
acid  the  albumin  will  ordinarily  coagu- 
late by  boiling  alone  and  precipitate  as 
a  whitish  powder  or  in  small  flakes.  The 
nitric  acid  is  nevertheless  in  all  cases  to 
be  added,  as  well  in  order  to  complete 
the  precipitation  of  albumin  as  to  avoid 
mistakes  caused  by  the  presence  of  a 
precipitate  of  phosphates  or  carbonates, 
• — which  will  immediately  dissolve  when 
nitric  acid  is  added.  This  test  is  ver}^ 
delicate  and  will  reveal  0.01  to  0.005  per 
cent,  of  albumin.  Instead  of  nitric  acid, 
acetic  acid  can  be  employed,  but  while 
the  nitric  acid  is  to  be  added  after  boil- 
ing and  in  a  quantity  of  5  to  10  drops, 
acetic  acid  is  added  before  the  boiling, 
and  only  a  sufficient  quantity  should  be 
employed  as  to  make  the  urine  but 
slightly  acid.  This  is  especially  neces- 
sary when  the  urine  is  alkaline,  because 
the  alkaline  albuminates  with  a  surplus 
of  acetic  acid  give  a  compound  which  is 
not  coagulated  by  boiling. 


ALBUMINURIA.     TESTS. 


179 


Heller's  Test. — Three  to  four  cubic 
centimetres  of  urine  are  poured  in  a  test- 
tube  and  two  cubic  centimetres  of  nitric 
acid  are  cautiously  floated  down  along 
the  sides  of  the  tube.  The  nitric  acid 
collects  on  the  bottom  of  the  test-tube, 
and  where  the  fluids  are  in  contact  a  dis- 
tinctly limited  disk  of  grayish-white  pre- 
cipitate will  appear.  When  only  traces 
of  albumin  are  present  the  precipitate 
will  only  take  place  after  some  minutes. 
The  more  or  less  distinct  yiolet  coloring 
which  also  appears  at  the  point  of  con- 
tact of  the  two  fluids  is  due  to  decom- 
posed indican.  This  test  is  very  delicate 
and  reliable;  0.003  per  cent,  of  albumin 
is  revealed  by  it. 

Fallacies.  —  By  the  addition  of  nitric 
acid  the  urates  are  also  precipitated; 
these  will  not  form  a  limited  disk,  but 
render  the  urine  turbid.  Eesinous  acids 
(copaiba)  are  precipitated  by  nitric  acid, 
but  are  dissolved  by  the  addition  of  con- 
centrated alcohol. 

Urea  may  also  become  a  source  of  error 

by  giving  a  precipitate  of  nitrate  of  urea. 

Long  (N.  Y.  Med.  Jour.,  Apr.,  '91). 

Test  bt  Acetic  Acid  and  Potassic 
Feekoctanide. — The  urine  is  rendered 
acid  by  acetic  acid,  and  some  drops  of 
a  solution  of  potassic  ferrocyanide  are 
added.  This  reagent,  the  serum-albu- 
min, the  globulin,  and  the  albumoses  are 
precipitated,  while  none  of  the  normal 
constituents  of  the  urine  are  (Huppert). 

Hetnsius's  Test. — A  still  more  deli- 
cate test  than  Heller's  is  that  of  Heyn- 
sius,  by  acetic  acid  and  sulphate  of  soda. 
The  iirine  is  rendered  acid  by  acetic  acid, 
and  an  equal  volume  of  a  saturated  solu- 
tion of  sulphate  of  soda  (or  of  common 
salt)  is  added.  The  mixture  is  boiled, 
and  all  kinds  of  albumin  will  then  be 
precipitated  in  white  flakes. 

The  Magnesium  -  Xiteic  Test 
(TiOBERTs's).  - —  One  cubic  centimetre  of 


nitric  acid  is  mixed  with  five  cubic  cen- 
timetres of  a  saturated  solution  of  sul- 
phate of  magnesium,  and  a  small  quan- 
tity of  this  mixture  is  added  to  the  urine. 
The  albumin  will  be  precipitated  as  a 
distinct  ring. 

Metaphosphoeic  acid  (Hinden- 
laxg)  also  precipitates  albumin  in  the 
same  manner  as  nitric  acid;  but  this  test 
is  not  as  delicate  as  that  of  Heller.  The 
solution  of  metaphosphoric  acid  must  be 
freshly  prepared  for  use,  as  the  solution 
easily  changes  to  orthophosphoric  acid 
upon  standing,  which  does  not  precipi- 
tate albumin. 

PicEic-AciD  Test  (Johnson). — A  few 
drops  of  a  saturated  solution  of  picric 
acid  will  cause  a  white  precipitate  when 
albumin  is  present;  this  test  is  only 
indicative  of  the  presence  of  albumin, 
however,  when  the  precipitate  appears 
immediately.  After  some  time  the 
iirates  and  the  creatinine  will  also  be 
precipitated  (Jaffe). 

Fallacies. — By  addition  of  picric  acid 
the  peptons,  the  resinous  acids, — such  as 
those  of  copaiba, — and  alkaloids — such 
as  morphine — are  precipitated. 

Peechloeide-oe-Meecuet  Test. — A 
5-per-cent.  solution  of  perchloride  of 
mercury  will  precipitate  albumin  in 
urine  which  is  rendered  acid  by  addi- 
tion of  a  few  drops  of  acetic  acid. 

Fallacies.  —  Xanthin  is  also  precipi- 
tated by  this  reagent. 

Millen's  Test. — A  solution  of  nitrate 
of  mercury  is  added  to  the  urine  and  the 
mixture  heated  to  boiling.  ISTitrate  of 
potash  is  then  added;  the  albumin  pre- 
sents as  a  precipitate  of  red  flakes. 

Taneet's  Test.  —  The  reagent  of 
Tanret  is  composed  of  perchloride  of 
mercury,  135  grammes;  iodide  of  potash,. 
3.33  grammes;  glacial  acetic  acid,  30' 
cubic  centimetres;  distilled  water,  sufii- 
cient   to   make    100    cubic    centimetres. 


180 


ALBUMINURIA.    TESTS. 


Some  drops  of  this  mixture  are  added 
to  the  urine,  and  will  coagulate  the  albu- 
min. It  will  also,  however,  precipitate 
the  urates.  Many  other  reagents  have 
been  recommended,  which  cannot  be 
mentioned  in  detail. 

A  small  crystal  of  trichloracetic  acid  is 
added  to  1  cubic  centimetre  of  urine 
previously  filtered;  when  the  acid  dis- 
solves a  sharply-defined  zone  of  turbidity 
arises  on  the  juncture  of  the  clear  urine 
and  that  saturated  with  the  acid.  Eaabe 
(Merck's  Bull.,  Apr.,  '91). 

A  solution  of  carbolic  acid  in  absolute 
alcohol  is  a  very  delicate  test  for  albumin 
in  the  urine,  comparing  very  favorably 
with  nitric  acid.  The  urine  should  first 
be  diluted  until  the  specific  gravity  is 
about  1.010;  a  few  cubic  centimetres  of 
carbolic  acid  is  then  poured  on  top  of 
this,  and  a  white  ring  is  immediately 
formed,  from  which  milky  drops  fall  to 
the  bottom  of  the  tube,  and  adhering  to 
this  are  the  flakes  of  albumin.  The  test 
is  sufficiently  delicate  to  show  0.000012 
gramme  in  1  cubic  centimetre  of  urine. 
W.  Colquhoun  (Lancet,  May  6,  1900). 

Xanthopeotein  Test. — Albuminous 
urine  heated  with  a  surplus  of  con- 
centrated nitric  acid  will  take  a  yellow 
color,  and  some  of  the  albumin  coagu- 
lates in  yellow  flakes,  which  are  soluble 
in  alkalies  with  an  orange-red  color. 

Thanspoetable  Eeagents  foe  Al- 
bumin".— Hoffmann  and  Aazette  employ 
strips  of  test-paper  previously  placed  in 
a  solution  of  the  double  iodide  of  potas- 
sium and  mercury  until  saturated,  then 
removed  and  dried.  The  urine  which  is 
to  be  tested  should  be  ckar  and  rendered 
acid  by  means  of  a  few  drops  of  acetic 
acid.  If  there  be  albumin  present,  upon 
immersion  of  a  slip  of  paper  in  the  urine 
a  distinct  precipitate  will  appear. 

Pavy  recommends  test-pellets  contain- 
ing ferrocyanide  of  soda  and  picric  acid; 
when  albuminous  urine  is  well  shaken 
with  a  parcel  of  the  pellet,  albumin  will 
l)e  precipitated.    The  relative  delicacy  of 


the  tests  most  frequently  employed  is 
graphically  represented  by  Unger-Vetle- 
sen,  in  the  diagram  shown  on  the  oppo- 
site page.  The  longest  columns  indicate 
the  most  delicate  tests. 

Sulphosalicylic  acid,  a  white  crystal- 
line substance  produced  by  heating  sali- 
cylic acid  with  concentrated  sulphuric 
acid,  precipitates  all  proteid  substances. 
It  shows  traces  of  albumin  in  a  dilution 
of  1  to  50,000.  This  reagent  was  first 
discovered  by  Eeoeh,  then  by  MaeWill- 
iam,  who  employs  sulphosalicylic  acid  in 
the  form  of  a  saturated  solution.  Per- 
sonally employed  by  adding  some  of  the 
crystals  to  a  small  quantity  of  filtered 
urine  contained  in  a  test-tube.  The  tube 
is  then  shaken.  If  albumin  is  present,  a 
white  homogeneous  precipitate  appears 
instantly.  The  urine  should  be  acid.  If 
the  urine  is  alkaline  it  efi'ervesces  after 
the  sulphosalicylic  acid  is  added.  If 
albumin  is  presented  in  the  smallest 
traces,  a  cloudiness  appears.  When  nitric 
or  acetic  acid  is  used  for  tests,  small 
traces  of  albumin  give  rise  to  stringy, 
multiform  particles  suspended  in  a  clear 
menstruum,  the  interpretation  of  which 
often  gives  rise  to  doubt.  Sulphosalicylic 
acid  gives  a  uniform  opalescence  which 
is  unmistakable.  Richard  Stein  (Med. 
Record,  Jan.  16,  '97). 

Fifty  samples  of  urine  investigated 
each  of  which,  from  character  of  sedi- 
ment, was  judged  to  contain  albumin. 
Those  urines  were  selected  in  which  small 
traces  only  of  albumin  were  assumed  to 
be  present.  With  Millard's  test,  reaction 
was  obtained  in  forty-eight  of  the  fifty 
specimens.  Two  samples  showed  no  re- 
action with  any  test;  so  that  with  Mil- 
lard's test  comparative  efficiency  would 
be  100  per  cent.  Roberts's  test  shoAved 
86  per  cent.;  potassium  ferrocyanide, 
66  per  cent.;  nitric  acid,  60  per  cent.; 
heat,  52  per  cent.  Dilutions  up  to  1  in 
320  showed  positive  results  with  all  the 
reagents.  When  strength  was  reduced  to 
1  in  640,  only  Millard's  test  showed  re- 
action, and  the  limit  to  the  reaction  was 
about  1  in  1280.  Unless  peptoii  is  pres- 
ent in  large  quantities,  it  is  not  precipi- 
tated by  action  of  Millard's  reagent.     J. 


ALBUMINURIA.    TESTS. 


181 


W.  Garratt   (N.  Y.  Med.  Jour.,  July  16, 
'98). 

A  glass  pipette  is  used  and  the  urine 
allowed  to  run  up  the  tube  one  or  two 
inches.  The  index  finger  is  then  placed 
on  the  top  and  the  urine  washed  and 
dried  off  the  outside  of  the  tube.  It 
is  then  inserted  into  nitric  acid  and 
the  index  finger  partially  removed 
to  allow  the  acid  to  flow  up  the 
tube.  The  presence  of  albumin  al- 
ways causes  a  white  ring  to  form  at 
the  line  of  contact.  Globulin,  albu- 
raoses,  and  peptones  may  also  cause  a 
small  ring  at  the  zone  of  contact,  but 


method  which  gives  fully  reliable  re- 
sults is  the  gravimetric  method.  One 
hundred  cubic  centimetres  of  urine  are 
cautiously  heated  to  the  boiling-point; 
if  precipitation  does  not  take  place  a  few 
drops  of  a  weak  solution  of  acetic  acid 
are  added;  the  liquid  is  now  brought 
on  a  weighed  filter  and  the  precipitate 
repeatedly  washed  with  hot  water.  When 
the  water  has  been  removed  from  the 
filter  by  strong  alcohol,  the  filter  is 
dried  by  a  temperature  of  120°  to  130° 


Ferrocyanide  of  potassium  and  ace- 
tic acid 

Solution  of  picric  acid 

Test-paper 

Solution   of   sulphate   of   soda   and 
acetic  acid 

Heller's  test 

Picric  acid  in  crystals 

Magnesium-nitric  test  (Roberts)  .  .  . 

Trichloracetic  acid 

Metaphosphoric  acid 

Boiling  and  nitric  acid 


12 

2A 

^r^ 

.44'. 

6  c 

2 

84 

96 

lOR 

I' 

la. 

they  are  seldom  present.  If  suspected 
they  may  be  tested  for  by  boiling  the 
urine.  A  cloud  appears  just  before  the 
boiling-point  is  reached,  but  disappears 
when  boiling  occurs.  Urates  may  cause 
a  similar  ring.  Similar  experiments 
have  been  tried  with  twelve  other  re- 
agents which  have  been  recommended 
for  detecting  albumin  in  urine,  but  the 
results  were  never  so  satisfactory  as 
when  nitric  acid  alone  was  used.  L. 
N.  Boston  (New  "York  Med.  -Jour.,  May 
24,  1902). 

Qtjaxtitative  Tests.  —  The  only 


C,  and  the  percentage  of  albumin  de- 
termined by  weighing. 

For  clinical  use  several  approximate 
methods  have  been  invented. 

Esbach  employs  an  albuminometer, — 
i.e.,  a  graduated  glass  tube:  this  tube 
is  filled  to  one  mark  {TJ)  with  the  urine 
and  then  to  the  mark  R  with  the  test- 
solution  consisting  of  picric  acid,  10 
grammes;  citric  acid,  20  grammes;  water, 
1  litre.  The  tube  is  then  closed  with 
a  rubber  stopper  and  the  contents  cau- 


182 


ALBUMINURIA.     TESTS. 


tiously  mixed.  The  mixture  is  allowed 
to  stand  undisturbed  for  twenty-four 
hours  and  the  quantity  of  precipitated 
albumin  then  read  off.  The  reading  in- 
dicates in  grammes  the  amount  of  albu- 
min per  litre. 

Christensen  recommends  another 
method:  the  albumin  contained  in  five 
cubic  centimetres  of  urine  is  precipitated 
by  ten  cubic  centimetres  of  a  watery 
solution  of  tannic  acid  (1  per  cent.). 
The  albumin  having  been  precipitated, 
1  cubic  centimetre  of  an  ordinary  gum- 
arabic  mucilage  is  added,  the  volume 
brought  up  to  50  cubic  centimetres  with 
water,  and  the  whole  converted  to  an 
emulsion  by  agitation.  Upon  a  piece  of 
white  paper,  ruled  with  black  lines  0.5 
millimetre  wide  and  at  equal  intervals, 
is  placed  a  cylindrical  glass  measuring- 
four  centimetres  in  diameter.  This  is 
half-filkd  with  water,  and  as  miich  of 
the  emulsion  run  in  as  possible  without 
obscuring  the  black  and  white  lines  be- 
neath the  vessel.  From  the  number  of 
cubic  centiiuetres  required,  reference  to 
a  table  of  calculations  arranged  by  Chris- 
tensen furnishes  the  proportion  of  albu- 
min present  in  the  emulsion.  When  tlie 
urine  is  alkaline  it  should  be  faintly  acidi- 
fied with  acetic  acid  before  the  precipita- 
tion of  albumin.  This  test  can  be  made 
as  well  by  daylight  as  by  the  light  of  a 
good  lamp,  and  requires  only  ten  or 
fifteen  minutes;  but  is  not  applicable 
to  urine  containing  a  small  amount  of 
albumin,  the  variations  amounting  to 
two-thousandths. 

The  polariscope  is  sometimes  employed 
to  estimate  the  quantity  of  albumin,  but 
this  test  is  not  very  reliable.  It  is  true 
that  albumin  is  Isevorotatory,  but  this 
is  also  the  case  with  normal  iirine,  and 
sometimes  the  color  of  the  urine  is  too 
dark  to  allow  the  use  of  the  polariscope. 

Miscellaneous.  —  Bv  the  tests  above 


mentioned,  as  well  qualitative  as  quan- 
titative, the  different  coagulable  proteids 
contained  in  the  urine  are  precipitated; 
it  is  rarely  of  any  use  to  differentiate 
them  one  from  another. 

Pure  globulinuria  without  the  simul- 
taneous presence  of  serum-albumin  does 
not  occur.  In  order  to  precipitate  the 
globulin  alone  the  urine  is  rendered 
alkaline  with  solution  of  ammonia,  after 
some  time  filtered,  and  the  filtrate  mixed 
with  an  equal  volume  of  a  saturated 
solution  of  sulphate  of  ammonia.  If 
globulin  be  present  a  flaky  precipitate 
will  appear. 

[The  same  result  can  be  obtained  by 
using  a  solution  of  sulphate  of  magnesia, 
which  does  not  precipitate  the  other 
proteids  of  urine,  or  by  diluting  the  urine 
until  it  reaches  a  specific  gravity  of  1002 
and  leading  a  slow  current  of  carbonic 
acid  through  it  for  tA\o  or  four  hours. 
After  twenty-four  to  twenty-eight  hours 
the  globulin  will  be  precipitated.    Levi- 

SON.] 

The  hemiallniniose,  or  propepton, 
which  seems  to  be  a  mixture  of  different 
albumoses,  may  be  revealed  by  saturation 
of  the  urine  with  chloride  of  soda  and 
addition  of  acetic  acid.  When  hemialbu- 
mose  is  present  a  precipitate  will  appear 
which  dissolves  by  the  addition  of  much 
acetic  acid  and  heating,  but  reappears 
when  the  liquid  cools  again. 

Nucleo-albumin,  in  small  quantity, 
seems  alwa3rs  to  be  contained  in  the 
urine.  It  is  revealed  by  the  addition  of 
an  excess  of  acetic  acid  to  the  itrine, 
which  becomes  turbid,  indicating  the 
presence  of  a  larger  quantity  of  nucleo- 
albumiu.  When  the  urine  is  very  much 
concentrated  it  should  be  diluted  with 
water  before  adding  the  acetic  acid,  as 
the  nucleo-albumin  is  held  in  solution 
by  the  salts  of  the  urine. 

F.  Levison, 

Copenhagen. 


ALCOHOL.     PHYSIOLOGICAL  ACTIOX. 


183 


ALCOHOL.  —  Alcohol  of  the  pharma- 
copceias  is  one  of  a  series  of  hydrocarbon 
compounds,  all  of  which  have  as  their 
base  a  radicle  called  ethj'l,  whose  chem- 
ical composition  is  expressed  by  the 
formula  CH.  Chemically,  alcohol  is  a 
hydrate  of  eth)^,  or  hydrated  oxide  of 
ethyl.  To  distinguish  it  from  other 
members  of  the  group,  particiilarly 
fusel-oil  (amyl-alcohol)  and  wood  spirit 
(methyl-alcohol),  the  alcohol  of  medicine 
is  called  ethjd-alcohol.  It  is  known  in 
the  British  Pharmacopceia  as  rectified 
spirit  or  rectified  spirits  of  wine,  from  its 
being  obtained  by  distillation  and  subse- 
quent rectification,  or  purification,  from 
a  mash  of  potatoes  or  grain,  or  from 
wine.  What  is  known  as  strong  alcohol 
contains  91  per  cent.,  by  weight,  of  pure 
spirit  (U.  S.  P.),  and  has  a  specific  grav- 
ity of  0.820.  Dilute  alcohol  contains 
45.5  per  cent.,  by  weight,  of  pure  spirit 
(U.  S.  P.),  with  a  specific  gravity  of 
0.928. 

Alcohol  is  usually  exhibited  in  medi- 
cine in  different  diluted  forms,  known 
as  beverages,  which  may  be  grouped  ac- 
cording to  the  percentage  of  alcohol 
present  in  them.  The  so-called  spirits 
(whisky,  brandj^,  rum,  gin,  arrack)  con- 
tain about  50  per  cent,  of  alcohol.  The 
heavy  wines  (port,  sherry,  Madeira,  etc.) 
contain  about  20  per  cent.,  but  are 
usually  too  sweet  for  the  use  of  sick 
persons;  when  "dry"  (free  or  nearly  free 
from  sugar),  they  are  frequently  useful 
to  convalescents  and  to  thos*  who  are 
debilitated.  The  light  table-wines  (claret, 
Burgundy,  champagne,  Tokay,  Moselle, 
hock,  and  Bhine  wines)  contain  from  5 
to  10  per  cent,  of  alcohol;  many  of  the 
Ehine  wines  are,  however,  not  suited  to 
those  having  a  tendency  to  the  oxalic 
diathesis,  on  account  of  the  oxalic  acid 
which  they  contain.  Malt  liquors  (ale, 
stout,  beer)  contain  diastase,  which  aids 


the  digestion  of  starchy  foods  and  tends 
to  produce  obesity.  They  are  especially 
tonic  in  their  effects  and  contain  from 
3  to  15  per  cent,  of  alcohol. 

Pure  alcohol  is  also  used  in  combi- 
nation with  various  tinctures  and  aro- 
matics,  to  secure  accuracy  of  dosage,  to 
avoid  the  effects  of  the  more  irritating 
ingredients  of  poor  or  bogus  liquors,  and 
often  in  private  practice  to  avoid  colli- 
sion with  the  prejudices  of  the  laity,  or 
again  when  there  is  a  tendency  toward 
the  abuse  of  alcoholic  beverages. 

Dose  and  Physiological  Action. — Alco- 
hol, in  prolonged  contact  with  the  skin, 
evaporation  being  prevented,  penetrates 
the  tissues  beneath  the  cuticle,  owing  to 
its  tolerably-high  diffusive  power,  and 
excites  a  sense  of  heat  and  superficial 
infiammation.  It  may  be  thus  employed 
as  a  counter-irritant.  Owing  to  its  vola- 
tility, alcohol  is  sometimes  used  topically 
to  cool  the  surface  of  the  body.  It  co- 
agulates albumin,  and  is  sometimes  used 
to  cover  sores  or  wounds  with  a  thin, 
protective,  air-excluding  layer,  which 
promotes  healing. 

Taken  internallj',  the  effects  vary  ac- 
cording to  the  size  of  the  dose  taken. 
When  a  small  dose  is  taken,  it  con- 
stringes  the  mucous  membrane  of  the 
mouth  and  throat  (often  used  diluted  as 
an  astringent  gargle  in  relaxed  throat, 
scurvy,  salivation,  etc.),  and,  on  reach- 
ing the  stomach,  it  produces  a  sense  of 
warmth,  which  is  quickly  followed  by 
a  feeling  of  general  well-being,  com- 
fort, and  restfulness.  The  heart-beat  is 
sometimes  accelerated;  the  arteries  are 
relaxed.  The  muscular  fibres  of  the  skin 
are  relaxed,  and  the  blood  becomes  more 
equally  distributed  over  the  different 
parts  of  the  body;  if  the  extremities  are 
pale  and  cold,  they  may  resume  their 
natural  color  and  temperature.  The 
glands    are    stimulated    generally;     the 


184 


ALCOHOL.    PHYSIOLOGICAL  ACTION. 


perspiration  is  increased;  the  amount  of 
urine  is  augmented,  and  the  secretions 
of  the  mucous  glands  throughout  the 
alimentary  tract  respond  to  the  increased 
stimulus.  The  appetite,  when  poor,  is 
improved,  the  special  senses  rendered 
more  acute,  and  relaxation  and  meteor- 
ism  of  the  intestines  are  relieved. 

In  the  stomach  a  double  action  is  ob- 
served on  both  the  gastric  juice  and  the 
secreting  membranes.  A  small  quantity 
of  alcohol  produces  an  insignificant  ef- 
fect on  the  pepsin  of  the  gastric  juice; 
a  larger  quantity,  however,  inhibits  or 
destroys  entirely  its  food-dissolving  ac- 
tion. In  like  manner,  a  small  quantity 
of  alcohol  augments  the  secretion  of 
the  gastric  juice;  larger  quantities  cause 
inflammation  of  the  mucous  membrane, 
with  increased  secretion  of  a  thick,  te- 
nacious mucus  and  a  loss  of  secreting 
power.  The  appetite  becomes  impaired 
or  lost  and  a  feeling  of  nausea  is  induced. 

Conclusions  as  to  the  influence  of  alco- 
hol upon  tissue-growth  and  cell-growth 
summed  up  as  follows:  1.  Alcohol  acts 
primarily  on  the  nerve-cells,  changing 
their  granular  matter,  breaking  up  their 
nutrition,  and  changing  their  dynamic 
force.  2.  This  action  is  followed  by  con- 
traction and  atrophy  of  the  dendrites; 
shrinking  of  cell-walls,  as  in  fatigue ; 
and  coalescence  and  disappearance  of  the 
granular  protoplasm.  3.  The  special  in- 
jury from  alcohol  seems  to  be  on  proto- 
plasm and  terminal  hbres  of  nerve- 
trunks;  the  irritation  and  inflammation 
of  the  nerve-walls  and  fibres  ending  in 
sclerosis  are  common.  4.  Alcohol  acts  on 
the  leucocytes,  checking  their  activity, 
and  destroying  their  function.  These  are 
driven  in  masses  by  the  increasing  rapid- 
ity of  the  heart,  and  become  blocked  in 
the  capillaries,  forming  centres  of  ob- 
struction and  injury.  5.  The  use  of  al- 
cohol is  followed  by  diminution  of  the 
carbon  dioxide  and  all  waste-elimination, 
with  marked  sensorial  palsy  and  slow- 
ing of  all  mental  actions.  T.  D.  Crothers 
(Jour.  Amer.  Med.  Assoc,  Nov.  26,  '98). 


Alcohol  has,  in  general,  a  very  slight 
germicidal  action.  At  normal  tempera- 
tures it  may  kill  non-spore-bearing  bac- 
teria, but  not  the  spore-bearers.  Its 
action  is  strongest  in  50-  to  70-per-cent. 
strength  and  weakest  when  in  strongest 
concentration  (absolute  alcohol).  When 
boiled,  or  heated  under  pressure,  it  acts 
according  to  its  percentage  of  contained 
water.  Alcoholic  solutions  of  disinfect- 
ants have  less  efl'ect  than  the  correspond- 
ing aqueous  solutions,  and  their  germi- 
cidal power  varies  inversely  as  the 
strength  of  the  alcohol  in  which  they  are 
dissolved.  Eafael  Minervini  (Zeitsch.  f. 
Hyg.  u.  Infects.,  Oct.  25,  '98). 

Actual  state  of  scientific  knowledge  on 
the  total-abstinence  question.  After  tak- 
ing small  amounts  of  alcohol  there  is  an 
apparent  temporary  increase  of  brain- 
activity,  which  is  but  as  an  evidence  of 
the  paralyzing  and  deleterious  efifect  of 
alcohol.  It  destroys  the  special  function 
of  the  cerebellum,  and  produced  tremor 
and  weakness  of  the  lower  limbs.  In 
chronic  alcoholism  the  dendrites  of  the 
pyramidal  nerve-cells  show  swellings  and 
shrinkages,  and  there  is  wide-spread  pig- 
mentation in  the  nerve-cells.  Even  small 
doses  of  alcohol  at  meals  have  a  dele- 
terious influence,  and  total  abstinence 
must  be  the  course  of  those  who  wish  to 
follow  the  plain  teaching  of  truth.  Vic- 
tor Horsley  (Lancet,  May  5,  1900). 

Alcohol  decreases  elimination  and  in- 
creases waste-products.  The  clear  in- 
dication of  the  autointoxication  of  alco- 
hol is  seen  when  functional  and  organic 
symptoms  disappear  by  abstinence. 
Crothers  (Jour.  Amer.  Med.  Assoc, 
Apr.  27,  1901). 

Alcohol  is  a  narcotic  poison.  Its  food- 
value  iTnder  ordinary  conditions  is  prac- 
tically nil,  and,  put  in  the  most  advan- 
tageous light,  can  only  be  temporary, 
and  then  of  an  extraordinary  slight  and 
wasteful  character.  G.  Sims  Woodhead 
(Edinburgh  Med.  Jour.,  Aug.,  1901). 

Series  of  experiments  to  determine  the 
influence  of  alcohol  upon  the  secretion 
of  the  gastric  juice:  upon  a  case  of 
gastroptosis,  one  of  hysteria,  one  of 
atony  of  the  stomach,  after  gastro-en- 
terostomy,  and  one  of  gastro-enteritis. 
The  alcohol  was   administered  per  ree- 


ALCOHOL.    POISONING. 


185 


turn,  and  the  patient  took  no  nourish- 
ment by  the  mouth.    It  was  found  that 
the   enema   caused   an   active   secretion 
of  gastric  juice  provided  the  amount  of 
alcohol  was  not  less  than  7  to  10  cubic 
centimetres.      The    acidity    reached   its 
maximum  about  an  hour  after  the  in- 
jections, and  then  gradually  decreased. 
In  two  cases  of  achylia  due  to  carcinoma 
of  the  stomach  no  effect  was  observed. 
E.  Spiro    (Miinchener  med.  Woch.,  No. 
47,  1901). 
Alcoholic  Poisoning.  —  The  toxic  ef- 
fects of  alcohol  are  those  of  an  irritant 
poison,  and  may  be  acute  or  chronic. 
The  acute  form  of  alcoholic   poisoning 
occurs  when  an  excess  has  been  taken  at 
once  or  within  a  short  interval  of  time. 
In  the  milder  form  the  ingested  alcohol 
produces  intense  irritation  of  the  stom- 
ach, with  increased  secretion  of  a  mucus 
altered  in  character,  nausea,  and  vomit- 
ing.   The  kidneys  are  the  seat  of  irrita- 
tion, the  result  of  which  is  an  increased 
secretion  of  urine.    If  the  irritation  be 
too  intense,  the  glomeruli  may  become 
so  swollen  as  to  diminish  or  even  pre- 
vent the   secretion   of  urine,  in  which 
latter  case  acute  temporary  suppression 
of  urine  results.     The  blood  becomes 
charged    with    the    abnormal    products 
(through  the  abnormal  condition  of  the 
stomach  and  its  secretions),  and  these 
are  excreted  by  the  renal  organs  in  the 
form  of  uric  and  oxalic  acids,  oxalate 
of  lime,  and  urates;    and,  from  over- 
stimulation of  the  nervous  system  and 
excessive  glandular  activity,  the  triple 
phosphates,  with  altered  pigment-matter; 
so  that,  following  an  alcoholic  excess,  a 
large  quantity  of  pale  urine  is  followed 
later  by  a  highly-colored,  strong-smell- 
ing secretion.  When  enormous  quantities 
are   ingested,   more    serious   symptoms, 
sometimes  even  followed  by  death,  re- 
sult.    The  symptoms  point  to  intense 
gastro-intestinal  irritation,  with  irrita- 
tion of  the  cerebro-spinal  system  so  great 


as    to    produce    convulsions,    coma,    or 
death. 

Definite  quantities  of  the  different  al- 
cohols administered  to  rabbits  b}'  means 
of  (Esophageal  tube.  Three  degress  of  in- 
toxication were  distinguished  according 
to  their  severity :  ( 1 )  slight  paralysis  of 
motion  and  sensibility;  (2)  total  paraly- 
sis of  motion  with  almost  complete  aboli- 
tion of  sensation;  (3)  coma,  often  ending 
in  death.  The  toxicity  rose  with  the 
boiling-point  of  the  alcohol,  methyl  being 
least  toxic  and  ethyl  coming  next,  while 
propyl  was  twice,  butyl  three  times,  and 
amyl  four  times  as  toxic  as  ethyl.  Ad- 
dition to  ethyl-alcohol  of  4  per  cent,  of 
an  alcohol  of  higher  boiling-point  in- 
creased the  toxicity  of  the  former  to  a 
marked  extent.  The  addition  of  2  per 
cent,  was  much  less  powerful,  while  1 
per  cent,  had  practically  no  effect  in 
increasing  the  toxicity.  Conclusion  is 
that  the  symptoms  of  acute  alcoholism 
are  not  due  to  impurities  in  the  ethyl- 
alcohol;  but  it  is  left  an  open  question 
whether  these  may  not  have  some  share 
in  producing  the  more  chronic  results  of 
alcoholic  excess.  Baer  (Arch.  f.  Anat.  u. 
Physiol.,  Oct.,  '98). 

Conclusions  regarding  effects  of  alcohol 
on  blood  are  as  follow:  1.  In  acute  alco- 
holic intoxication  the  carbonic  acid  as 
well  as  the  alkalinity  is  greatly  reduced, 
due  to  the  fact  that  there  is  an  increase 
of  volatile  fatty  acids,  which,  for  the 
moment,  displace  the  carbonic  acid.  The 
decrease  of  the  red  corpuscles  cannot  be 
of  importance,  as  it  is  not  constant.  2. 
The  effects  of  chronic  alcoholism  make 
themselves  fully  manifest  only  after 
several  months.  The  alkalinity  remains 
about  normal;  the  oxygen  decreases, 
and  later  also  the  carbonic  acid.  Thomas 
(Arch.  f.  exper.  Path.  u.  Pharm.,  B.  41, 
H.  I,  Mar.,  '98). 

Fatal  acute  alcohol  poisoning  in  a 
child  six  years  and  three  months  old, 
who  between  8.30  and  9.30  a.m.,  on  an 
empty  stomach,  drank  about  3  ounces 
of  whisky.  Death  occurred  by  cardiac 
failure  about  twenty  hours  after  the 
drinking  of  the  whisky.  M.  A.  Walker 
(N.  Y.  Med.  .Jour.,  Aug.  19,  '99). 

Case  of  blindness  from  drinking  meth- 


186 


ALCOHOL  IN  THERAPEUTICS. 


ylic  alcohol,  the  tenth  case  recorded,  the 
patient,  a  German^  aged  45,  who  drank 
about  V3  pint  of  a  mixture  of  one-third 
^yood-aleohol  and  two-thirds  water.  The 
following  day  he  had  some  of  the  same 
potation;  and,  on  the  day  after,  violent 
vomiting  set  in,  with  extremely  severe 
headache  and  foggy  vision.  A  fortnight 
later  he  had  no  light-perception,  and  the 
pupils  were  large  and  irresponsive  to 
light,  the  outer  halves  of  the  disks  were 
decidedly  atrophic,  and  their  margins 
very  slightly  blurred.  Some  improve- 
ment in  vision  proved  to  be  but  tempo- 
rary; he  is  now  quite  blind.  "Wood- 
alcohol,"  or  methylic  alcohol,  is  a  very 
poisonous  substance,  and  has  been  the 
cause  of  a  number  of  deaths.  Giflord 
(Ophth.  Record,  Sept.  and  Dec,  '99). 

Retardation  of  the  pulse  is  brought 
about  by  an  irritation  of  the  vagus 
centres,  and  of  the  peripheral  ends  of  the 
vagi,  in  part  due  to  a  direct  cardiac 
action.  The  fall  in  blood-pressure  is 
due  to  a  direct  injurious  influence  upon 
the  heart-muscle.  Ladislas  Haskovec 
(Wiener  med.  Blatter,  Get.  11,  1900). 

Treatment  of  Alcoholic  Poisoning.  — 
The  treatment  of  acute  alcoholic  poison- 
ing (drunkenness)  is  best  begun  by  wash- 
ing out  the  stomach  either  by  emetics 
or  by  the  stomach-pump  or  by  ingestion 
of  large  quantities  of  warm  water.  Com- 
plete rest,  induced,  if  necessary,  by  large 
doses' of  one  of  the  bromides,  and  relief 
of  nausea  and  depression  by  large  doses 
of  ammonia  (spirit  of  Mindererus,  or 
aromatic  spirit),  are  of  prime  importance. 
The  cold  pack  is  also  of  great  use.  The 
use  of  coffee  in  large  doses  (in  both 
acute  and  chronic  cases)  refreshes  and 
stimulates  the  nervous  system,  and  with 
rest  and  warmth  assures  a  rapid  recovery. 

If  convulsions  and  coma  are  present 
rectal  injections  of  chloral  ma}^  be  used, 
followed  by  the  cold  pack.  Atropine, 
digitalis,  and  morphine  may  also  be  of 
service,  though  the  prognosis  is  usually 
fatal.    (See  Alcoholism.) 

Therapeutics.  —  There  is  considerable 


divergence  of  opinion  as  regards  the  use 
of  alcohol  in  disease.  The  older  view  is 
that  it  is  a  valuable  agent  when  judi- 
ciously employed,  and  that  stimulants 
are  especially  indicated  in  cases  of  fa- 
tigue, in  convalescence  from  acute  dis- 
eases, in  persons  who  live  a  sedentary 
life,  or  who  suffer  from  poor  digestion, 
and  in  others  who  are  prostrated  from 
acute  illness.  In  all  these  cases  a  glass 
of  wine  or  a  little  brandy  diluted  with 
water,  taken  shortly  before  or  with  the 
food,  is  thought  to  stimulate  the  digest- 
ive organs  and  enable  the  patient  to  take 
more  food.  Pure  alcohol  is  sometimes 
given  alone  or  in  combination  with  some 
bitter  tincture,  as  tincture  of  calumba  or 
quassia,  or  compound  tincture  of  gentian 
or  cinchona. 

Observations  in  man  on  the  influence 
of  alcohol  on  muscular  work,  by  means 
of  Mosso's  ergograph:  an  arrangement 
something  like  an  extension  apparatus, 
with  a  weight  and  pulley  on  which  mus- 
cular traction  can  be  made,  the  amount 
of  work  done  being  registered  in  kilo- 
grammeters  graphically.  Summary  of 
the  results:  — 

1.  Moderate  quantities  of  alcohol  have 
an  appreciable  influence  on  the  working 
capacity  of  muscles;  but  this  differs  in 
the  fatigued  and  fresh  muscle. 

2.  In  the  unfatigued  muscle  alcohol 
lessens  the  extent  of  its  maximum  con- 
traction, owing  to  decrease  of  peripheral 
irritability  of  the  nervous  system. 

3.  In  the  fatigued  muscle  alcohol  in- 
creases the  working  capacity,  as  its 
extensibility  is  increased. 

4.  A  fatigued  muscle,  however,  under 
the  influence  of  alcohol,  never  attains  to 
the  working  power  of  an  unfatigued 
muscle,  because  the  lessening  of  the 
peripheral  nervous  Irritability  by  the 
alcohol  interferes  with  the  development 
of  its  full  working  power. 

5.  The  action  of  alcohol  on  muscle  is 
developed  in  a  very  few  minutes  after 
it  has  been  swallowed,  and  lasts  a  con- 
siderable time. 

6.  In  all  cases  the  alcohol  diminishes 


ALCOHOL  IN  THERAPEUTICS. 


187 


the  feeling  of  fatigue,  and  the  work  ap- 
pears easier. 

7.  After  moderate  amounts  of  alcohol 
the  increase  is  not  followed  by  any  de- 
crease in  the  muscular  power  of  fatigued 
muscles;  after  large  amounts  of  alcohol 
the  sj'mptoms  of  muscular  paresis  are 
prominent,  and  increase  with  the  dose. 

Alcohol,  therefore,  has  a  twofold  action 
on  muscular  work:  first,  on  the  nervous 
system  it  diminishes  centrally  the  feeling 
of  fatigue,  and  peripherally  the  excita- 
bility; while,  secondly,  it  furnishes  food- 
material  Avhieh  can  be  oxidized  to  pro- 
duce energy  and  work.  Hermann  Fey 
(Edinburgh  Med.  Jour.,  Sept.,  '97). 

Series  of  investigations  on  effects  of 
alcohol.  One  ounce  of  alcohol  greatly 
reduced  the  perception  (Ach).  Capacity 
for  calculating  lessened,  but,  while  alco- 
hol lessened  the  ability  to  reckon  accu- 
rately, the  work  was  easier  (Vogt).  The 
capacity  for  physical  work  increased 
about  one-third  after  the  ingestion  of 
alcohol,  but  in  ten  minutes  this  increase 
had  almost  entirely  disappeared.  It  did 
not  really  increase  the  strength.  When 
alcohol  is  added  to  the  fatigue  products 
of  the  muscles  the  depressing  effect  be- 
comes very  marked.  Kest  after  taking 
alcohol  prevents  any  noticeable  diminu- 
tion in  strength;  but,  if  the  action 
demands  the  utilization  of  strength, 
fatigue  rapidly  comes  on  (Gluek).  The 
effect  of  alcohol  varies  remarkably  in 
different  men;  the  degree  of  sensitive- 
ness to  the  poison  might  at  times  be  less 
in  those  not  addicted  to  its  use  than  in 
those  accustomed  to  it  (Eudin). 

General  conclusion  that  whoever  knows 
the  effects  of  alcohol  will  not  class  this 
substance    among   the    harmless    agents. 
Kraepelin  (Miinch.  med.  Woch.,  Oct.  17, 
'09). 
According  to  Harnack,  who  has  closely 
■studied  the  question,  alcohol  in  small  or 
medium  doses  exercises  simultaneotisly 
a  stimulating  action  upon  certain  func- 
tions and  a  depressing  action  upon  others. 
This  fact  should  never  he  lost  sight  of; 
otherwise  the  physician  exposes  himself 
to   the   danger  of  injuring  instead   of 
benefiting  his  patient.     It  should  also 


never  be  forgotten  that,  even  in  small 
doses,  the  paralyzing  action  of  alcohol 
is  exercised  most  rapidly  and  most  ener- 
getically upon  the  tonus  of  the  blood- 
vessels,— the  importance  of  which  tonus 
for  the  regularity  of  the  circulation  and 
the  preservation  of  cardiac  energy  is 
well  known.  For  this  reason  alcohol 
should  be  given  with  caution  in  cases  in 
which  the  heart  is  already  enfeebled,  as 
in  acute  diseases  of  long  duration,  or  in 
convalescence  from  such  affections.  It 
sometimes  happens  that  the  patients 
themselves  refuse  alcoholics;  in  which 
case  they  should  never  be  compelled  to 
take  them,  but  should  be  given  digitalis 
instead,  which,  even  in  small  doses  (5 
minims  in  6  ounces  of  water),  acts  solely 
upon  the  heart,  but  in  this  way  estab- 
lishes the  tone  of  the  blood-vessels.  The 
acceleration  of  pulse,  often  observed 
after  the  administration  of  digitalis,  is 
doubtless  due  to  the  improved  nutrition 
of  the  cardiac  muscle. 

The  use  of  alcohol  as  a  stimulant  or 
tonic  in  the  treatment  of  disease  is  de- 
lusive and  more  or  less  injurious.  By 
diminishing  the  internal  distribution  of 
oxygen  and  the  activity  of  the  leucocytes 
it  directly  diminishes  man's  vital  resist- 
ance to  the  action  of  all  morbific  causes, 
while  by  its  ansBsthetio  effect  on  the  cere- 
bral convolutions,  it  lulls  him  into  a  false 
feeling  of  security.  N.  S.  Davis  {Med. 
Pioneer,  Oct.,  '94). 

Alcohol  removes,  in  great  measure,  the 
controlling  influence  of  the  smaller  arter- 
ies on  the  heart,  and  causes,  also,  paresis 
of  the  vagus.  The  result  is  increase  in 
the  number  of  cardiac  beats,  dilatation 
of  surface-vessels,  a  feeling  of  surface- 
warmth,  with  reduction  of  the  tempera- 
ture of  the  body.  It  can  scarcely  be 
considered  a  food,  as  in  itself  it  contains 
no  one  of  the  constituents  of  which  the 
body  is  made.  It  gives  no  warmth  to 
the  body.  This  is  proved  by  the  ther- 
mometer. The  disuse  of  it  by  deer- 
stalkers, Canadian  hunters,  and  Arctic 
explorers  is  additional  proof  of  this.     It 


188 


ALCOHOL  IN  THERAPEUTICS. 


gives  no  strength.  It  distinctly  weakens 
the  muscles.  Professor  Parkes  realized 
this  by  experiment  in  the  last  Ashantee 
War.  Acting  on  the  same  views,  the 
Great  Western  Raihvay,  during  the  alter- 
ation of  rails  along  the  whole  line,  sub- 
stituted oatmeal-gruel  for  alcohol,  be- 
cause the  work  had  to  be  done  with 
rapidity  and  with  unusual  energy.  The 
relief  of  Chitral  tells  the  same  story,  and 
so  do  our  great  national  games.  It  does 
not  lengthen  life.  Long  Fox  (Bristol 
Medico-Chir.  Jour.,  Mar.,  '96). 

Fevees. — While  alcohol  is  very  useful 
in  many  cases  of  fever,  there  can  be  no 
reasonable  doubt  that  all  cases  of  fever 
do  not  require  it,  while  many  cases  are 
best  treated  without  it.  The  special  in- 
dications for  its  exhibition  are:  general 
debility;  rapid,  small,  or  irregular  pulse; 
the  condition  known  as  the  typhoid  state 
and  recognized  by  the  presence  of  hebe- 
tude, indifference,  jactitation,  muscular 
twitching,  subsultus  tendinum,  mutter- 
ing delirium;  coma  vigil  or  even  a  more 
active  delirium,  with  signs  of  great  weak- 
ness; a  dry  or  brown  tongue,  sordes, 
and,  perhaps,  involuntary  evacuation  of 
urine  or  fasces.  If  the  patient  is  being 
benefited  by  the  use  of  stimulants,  the 
following  effects  will  be  observed:  The 
tongue  becomes  moist;  the  pulse  becomes 
slower;  the  skin  becomes  comfortably 
moist;  the  breathing  becomes  more  and 
more  tranquil;  sleep  is  produced;  delir- 
iiim  is  quieted  or  disappears. 

While  alcohol  should  not  be  given  in 
every  case  of  fever,  certain  definite  indi- 
cations exist  which  imperatively  call  for 
its  use:  1.  Persistence  of  a  high  tem- 
perature. 2.  Persistence  of  a  rapid, 
feeble,  irregular,  dicrotic  pulse,  whether 
associated  with  high,  low,  or  irregular 
temperature.  3.  Persistence  of  marked 
prostration. 

If,  however,  after  giving  alcohol  the 
pulse  becomes  quicker  and  more  irreg- 
ular, the  skin  hotter  and  drier,  tongue 
browner  and  drier,  breathing  shallower 
and  hollower,  it  means  that  the  alcohol 


is  doing  no  good  even  if  it  is  doing  no 
harm;  it  means  that  the  little  patient 
has  passed  from  the  stage  of  depression, 
in  which  alcohol  is  of  decided  utility,  to 
the  stage  of  exhaustion  of  the  vital  pow- 
ers, in  which  it  is  of  no  value;  nor  is 
any  other  remedy,  for  that  matter.  Un- 
der such  circumstances  alcohol  had  best 
be  discontinued.  Depression  of  vital 
powers,  no  matter  how  alarming,  can  be 
successfully  combated  by  alcohol  in  con- 
junction with  other  powerful  and  quickly 
acting  stimulants.  Exhaustion  of  the 
vital  powers,  whether  in  old  age  or  in- 
fancy, means  death.  A.  E.  Bieser 
(Pediatrics,  Apr.  1,  1901). 

Poisoned  Wounds.  —  Alcohol  is  a 
valuable  remedy  in  the  toxaemia  pro- 
duced by  poisoned  wounds,  snake-bites, 
etc.,  if  used  immediately  and  freely.  In 
these  conditions  the  dose  is  to  be  regu- 
lated by  the  effect,  as  very  large  doses 
are  not  only  tolerated,  but  required,  to 
be  of  any  use. 

Aconite  Poisoning.  —  Stimulants, 
freely  administered  (best  by  hypodermic 
injection  for  rapid  action),  are  useful  in 
this  grave  condition,  in  which  the  whole 
plan  of  treatment  is  directed  toward 
stimulation  and  the  prevention  of  syn- 
cope.   (See  Aconite.) 

Externally.  —  Alcohol  used  exter- 
nally is  detergent,  antiseptic,  disinfect- 
ant, astringent,  and  haemostatic.  These 
properties  make  it  a  valuable  agent  in 
the  treatment  of  woimds,  especially  if 
the  seat  of  infection.  Whisky,  plain  or 
diluted  (1  to  4),  may  be  used.  For  non- 
infected  wounds  and  granulating  ulcers 
the  vinum  aromatieum  (U.  S.  P.)  is  a 
valuable  dressing. 

In  snake-bites  and  insect-stings,  strong 
alcohol  combined  with  ammonia  is  a 
useful  lotion  after  the  poison  has  been 
sucked  out  of  the  wound. 

Alcohol  (8  p.)  combined  with  am- 
monium chloride  (1  p.),  vinegar  or  dilute 
acetic  acid  (4  p.),  and  water  (64  p.)  makes 


ALCOHOL  IN  THERAPEUTICS. 


189 


a  valuable  evaporating  lotion,  which  may 
be  perfumed  if  desired.  This  is  useful 
in  headache;  strained  and  swollen  joints, 
muscles,  and  tendons;  abscesses,  ery- 
thema, erysipelas,  and  slight  burns.  For 
bathing  fever  patients,  alcohol  is  useful, 
alone,  or  combined  with  vinegar  when 
there  is  diffuse  diaphoresis. 

Alcohol  is  used  as  a  detergent,  alone, 
or  combined  with  sodium  bicarbonate 
(2  p.),  alcohol  (8  p.),  water  (80  p.),  or 
in  the  form  of  soap  liniment.  Applied 
to  irritated,  fissured,  or  excoriated  nip- 
ples, dilute  alcohol  hardens  the  surface, 
and  coats  the  raw  surfaces  with  a  deli- 
cate protective  film  (by  coagulating  the 
albumin  in  the  secretion  of  the  raw  sur- 
face) and  diminishes  the  sensibility  of 
the  terminal  nerve-filaments. 

Ulcers  or  aphtlije  are  benefited  by  the 
local  application  of  strong  alcohol. 

The  disinfecting  properties  of  alcohol 
are  asserting  themselves  increasingly. 

A  dilution  of  alcohol  of  55  to  100  is 
toxic  to  staphylococci  and  is  but  slightly 
inferior  to  1-to-lOOO  corrosive  sublimate, 
and  equal  to  carbolic  acid  in  3  parts  per 
100.  Alcohol  to  which  is  added  an 
alkali  for  the  purpose  of  saponifying  fat 
greatly  increases  the  disinfecting  powers. 
A  dilution  of  80  parts  in  100  is  an  ex- 
ceedingly efficient  disinfectant  for  the 
hands.  G.  Fisher  (La  Presse  Med.,  July 
7,  1900). 

Property  of  alcohol  in  the  sterilization 
of  the  hands.  It  is  in  abstracting  air 
from  the  pores  and  fissures  of  the  skin 
that  the  true  value  of  the  application 
lies;  a  previous  treatment  with  alcohol 
enables  subsequent  aqueous  solutions  to 
penetrate  much  more  thoroughly  and 
completely  into  all  the  macroscopical 
and  microscopical  interstices  of  the  cuta- 
neous surface.  Braatz  (Miinch.  med. 
Woch.,  July  17,  1900). 

Permanent  applications  of  strong  alco- 
hol of  great  service  in  combating  all  in- 
flammatory conditions  in  which  there 
is  a  tendency  toward  suppuration.  It 
causes  a  local   dilatation   of   the   blood- 


vessels, and  thereby  the  formation  of 
alexins  and  consequent  greater  capacity 
for  resisting  the  spread  of  infection. 
Thick  layers  of  gauze  are  saturated  with 
alcohol  and  then  covered  with  some  im- 
pervious material.  The  dressing  is  left 
in  place  for  days  at  a  time,  resaturating 
it  with  alcohol  once  every  twelve  hours. 
Graeser  (Miinch.  med.  Woch.,  July  17, 
1900). 

In  disinfection  with  alcohol  the  vapor 
is  the  effective  element.  Von  Brun 
(Miinchener  med.  Woch.,  Feb.  12,  1901). 

In  the  various  preparations  of  alcohol, 
those  W'ith  a  higher  specific  w-eight  have 
more  energetic  disinfectant  action.  The 
most  energetic  preparation  is  40-per-cent. 
alcohol,  which  boils  at  about  90°  C. 
Frank  (Miincliener  med.  Woch.,  .Jan.  22, 
1901). 

Inhalations. — Inhalations  of  alcohol 
have  proved  useful  in  the  treatment  of 
shock,  collapse,  and  the  profound  asthe- 
nia met  with  in  fevers  and  toxic  condi- 
tions, especially  when  alcohol  cannot  be 
taken  by  the  mouth  or  given  by  the  rec- 
tum. A  10-per-cent.  solution  of  alcohol 
may  be  administered  by  steam  or  hand- 
spray  apparatus,  or  by  pouring  alcohol 
or  spirits  into  a  vessel  of  hot  water, 
throwing  a  towel  over  the  vessel  and  the 
patient's  head. 

IN.TECTIONS.  —  Tumors.  —  The  use  of 
alcohol  in  carcinoma  has  been  productive 
of  encouraging  results.  Interstitial  in- 
jections of  very  strong  alcohol  have  been 
used  by  Vulliet,  of  Geneva,  as  a  palliative 
in  inoperative  cases  of  cancers  of  the 
uterus.  The  beneficial  action  obtained 
this  author  ascribed  to  the  local  ischsemia 
induced. 

Carcinoma  of  the  uterus  was  also 
treated  in  1878  by  Hasse  with  alcohol, 
injections  being  made  into  the  circum- 
ference of  the  growths  in  three  cases 
with  good  results.  After  twenty-three 
years  the  patients  were  alive  and  well. 
There  had  been  formation  of  connective 
tissue  around  the  neoplasm,  obliteration 


190 


ALCOHOL  IN  THERAPEUTICS. 


of  the  blood-vessels,  and  shrinking  of  the 

tumor. 

To  prevent  the  recurrence  of  growths 
a  mixture  of  30  parts  of  absolute  alcohol 
to  70  parts  of  water  should  be  injected 
twice  a  week  around  the  tumor.  0. 
Hasse  (La  Semaine  Med.,  Oct.  16,  '95). 

Alcohol  as  a  curative  measure,  inject- 
ing it  into  various  tumors.  Ten  to  20 
minims  are  injected  in  one  side  of  tumor, 
then  as  much  in  another  place;  con- 
tinued till  every  part  is  touched  with 
alcohol.  J.  W.  Young  (Charlotte  Med. 
Jour.,  July,  '95). 
More  recently  this  treatment  has  been 

employed  in  cancer  of  the  breast  with 

encouraging  results. 

Case  of  cancer  of  the  naso-pharynx  in 
which  the  injection  of  unfiltered  ery- 
sipelas-prodigiosus  toxins  had  failed.  In 
view  of  the  inevitable  fatal  outcome,  in- 
jection of  alcohol  after  the  method  of 
Sehwalbe  and  Hasse  tried.  The  injec- 
tions Avere  begun  on  October  14,  1896, 
beginning  with  3  minims  of  absolute 
alcohol  and  rapidly  increasing  to  30 
minims.  The  reduction  in  size  began 
after  the  seventh  injection,  and  after  the 
eleventh  but  few  remnants  of  the  growth 
remained.  After  a  dozen  or  more  injec- 
tions the  needle  would  not  penetrate  into 
tissues  capable  of  retaining  the  alcohol, 
and  after  a  few  additional  attempts,  at 

,  intervals  of  a  week  or  longer,  they  were 
discontinued.  In  February,  1S97,  the 
naso-pharynx  was  found  both  by  inspec- 
tion and  palpation  to  be  entirely  free 
from  growth  or  any  suggestion  thereof. 
Examination  of  secretions  of  tumor  con- 
firmed the  diagnosis  of  cancer.  Edwin 
J.  Kuh  (Medical  Record,  Apr.  17,  '97). 

Case  of  cancer  of  the  breast  treated  by 
injections  of  alcohol.  On  February  20th, 
with  a  mixture  of  40  parts  absolute 
alcohol  and  60  parts  distilled  water,  23 
syringefuls,  each  of  20  minims,  were  in- 
jected deeply  into  the  tissues  all  around 
the  tumor,  and  into  the  axilla  in  the 
neighborhood  of  the  enlarged  glands. 
The  injections,  averaging  from  22  to  25 
syringefuls  each  time,  were  repeated 
about  every  fifth  day  until  May  2.  Each 
sitting  occupied  about  three-fourths  of 
an  hour;    the  injected  fluid  had  a  great 


tendency  to  run  back  again,  to  obviate 
which  a  smear  of  collodion  over  the 
needle-pricks  is  the  best  preventive.  The 
patient  experienced  considerable  immedi- 
ate pain  from  the  injections,  lasting 
from  one-half  to  one  hour.  After  the 
second  series  of  injections  the  patient 
declared  that  the  sensations  in  the  breast 
were  altered,  the  shooting  pains  were  no 
more  felt,  and  the  itching  on  the  surface 
of  the  breast,  which  she  had  complained 
of,  disappeared  and  never  recurred.  After 
the  subsidence  of  the  immediate  painful 
effects  of  all  the  other  injections,  the 
patient  felt  more  comfortable  in  every 
way.  When  the  process  had  been  con- 
tinued for  five  weeks,  "'.he  parts  around 
the  tumor  began  to  be  oedematous,  but 
still  the  injections  were  continued  into- 
and  beyond  the  oedematous  parts.  Dur- 
ing the  sixth  week  the  patient  and  her 
nurse  stated  that  they  considered  that 
the  growth  was  less,  and  certainly  at  the- 
beginning  of  the  eighth  week  (Aprii 
11th)  the  whole  breast,  including  the 
tumor,  had  diminished  in  size. 

After  this  date,  all  the  parts,  breast 
and  tumor,  rapidly  shrunk,  until  in  May 
there  was  actually  nothing  left  of  the 
mamma  to  be  felt  bj'  the  hand,  and  prac- 
tically nothing  left  of  the  tumor  but  the 
nipple  and  slight  thickening  under  it. 
There  was  still  oedema  in  the  injected' 
area.  The  glands  in  the  axilla  could  not 
be  detected.  At  this  time  Mr.  Windsor 
examined  the  case  (May  12th)  and 
stated  "that  whilst  the  right  was  a  fairly 
large  hanging  breast,  the  other — the  left 
breast — had  practically  disappeared,  the 
nipple  only  remaining;  that  he  did  not 
find  any  thickening  under  the  pectoralis 
nor  enlarged  glands  in  the  axilla."  After 
these  seventeen  injections,  a  complete 
structural  change  to  all  appearance  hav- 
ing taken  place,  it  was  intended  to  con- 
tinue the  injections  at  longer  intervals 
for  a  considerable  time,  but  unfortu- 
nately the  patient  became  ill  otherwise. 
She  lost  her  appetite,  became  slightly 
jaundiced,  and  on  examining  her  in  bed 
on  May  16th  it  was  found  she  was  suffer- 
ing from  cancer  of  the  liver  with  ascites. 
This  being  the  case  nothicg  further  was 
done;  the  patient  rapidly  got  worse,  and 
died   on  June   10th.     The  mamma  was 


ALCOHOL  IN  THERAPEUTICS. 


191 


found  to  be  replaced  by  a  dense,  fibrous- 
looking  mass  with  several  processes  ex- 
tending  into   the    surrounding    fat    and 
firmly  connected  with  the  subjacent  pec- 
toral   muscles.      The    skin    was    rough, 
superficially  ulcerated  at  one  place,  and 
adherent  to  the  subjacent  tissue  around 
the   nipple.     The   nipple   was   depressed, 
but  not  considerably  retracted.    William 
Yeats  (Brit.  Med.  Jour.,  Sept.  25,  '97). 
In  cases  of  shock,  collapse,  typhoid 
state,    and    profound    asthenia,    where 
stimulants  cannot  be  swallowed,  whisky 
or  other  spirits  may  be  injected  hypo- 
dermicallj',  with  the  advantage  of  rapid 
absorption  and  speedy  action,  according 
to  some  authors,  but  the  belief  is  gaining 
ground   that  it  is  more   harmful  than 
beneficial. 

[We  are  glad  to  observe  that  the  truth 
concerning  the  noxious  action  of  alcohol 
in  narcosis  from  anaesthetics,  determined 
by  Wood  in  his  able,  experimental  re- 
searches, has  begun  to  be  disseminated, 
aB  it  certainly  deserves.    We  believe  that 
the  use  of  hypodermic  injections  of  alco- 
hol in  chloroform  or  ether  narcosis,  as 
recommended   and   employed   heretofore, 
has  been  an  error,  and  should  be  aban- 
doned.     Griffith    and    Cerna,    Assoc. 
Eds.,  Annual,  '93.] 
Alcohol  is  a  useful  food  in  the  small 
quantity  which  increases,  but  does  not 
impair,   digestion;    which  quickens  the 
circulation  and  the  secreting  function  of 
the  glands,  but  does  not  overstimulate; 
and  which  can  be  oxidized  in  the  body. 
This  amount,  says  Bartholow  and  others, 
is  from  1  ounce  to  1  Va  ounces  of  absolute 
alcohol  for  a  healthy  adult  in  twenty- 
four  hours.    All  excess  is  injurious. 

In  small  doses  alcohol  stimulates  the 
stomach,  and  consequently  promotes 
hyperchlorhydria  and  hyperacidity  of 
that  organ.  In  large  doses  it  loses  its 
stimulating  action,  and  the  chlorhydric 
action  upon  albuminoids  :s  either  weak 
or  wanting.  M.  P.  Haan  (Piogres  M6d., 
Dec.  21,  '95). 
The  prolonged  indulgence  in  alco- 
holic drinks  in  time  produces  a  chronic 


catarrhal  inflammation  of  the  gastric 
mucous  membranes,  accompanied  by  a 
proliferation  of  the  connective  tissues.. 
This  latter,  by  subsequent  contraction,, 
obstructs  and  finally  obliterates  the- 
secreting  follicles  and  the  cells  whiclv 
line  them.  In  this  way  the  mucous- 
membrane  becomes  thickened,  indurated,, 
and  uneven,  and  covered  with  a  coating 
of  thick,  tenacious  mucus  that  excites- 
fermentation,  with  gas  and  various  acids 
(butyric,  acetic,  etc.);  whence  acidity 
and  heart-burn. 

These  harmful  effects  on  the  stomacb 
are  much  less  marked  in  fever  patients- 
and  in  those  who  are  convalescing  from 
exhausting  diseases. 

In  infectious  diseases  alcohol  should 
never  be  given  unless  the  patient  is  near 
collapse.  Even  in  small  doses  it  weakens, 
the  resistance,  and  so  favors  the  action 
of  the  invading  microbe.  It  is  a  cause 
of  still-bora  infants,  with  more  or  less 
wide-spread  fatty  degeneration.  Gruber- 
(Wiener  klin.  Woch.,  May  9,  1901). 

As  the  diffusive  power  of  alcohol  is 
great,  it  passes  readily  into  the  blood;, 
little  finds  its  way  very  far  into  the  in- 
testines. The  effects  of  alcohol  on  the 
other  organs  of  the  body  (liver,  kidneys,, 
brain,  and  vessels),  as  it  passes  through 
them  on  its  way  in  the  circulation,  will 
be  considered  under  Poisoning. 

Even  in  large  qvtantities,  alcohol  ap- 
pears neither  to  promote  nor  to  hinder- 
the  conversion  of  starch  into  sugar. 

Parkes  and  WoUowicz  hold  that  alco- 
hol does  not  diminish  the  oxidation  of 
the  body.  G.  Harley  found  that  alcohol, 
added  in  small  quantities  to  blood  with- 
drawn from  the  body,  lessened  its  ab- 
sorption of  oxygen  and  its  elimination  of 
carbonic  acid. 

As  to  the  effect  of  alcohol  on  the  body- 
temperature,  it  would  seem  that  a  small 
quantity,  in  a  subject  not  accustomed  to 
its  iise,  causes  increased  activity  in  all. 


193 


ALCOHOL  IN  THERAPEUTICS. 


the  bodily  functions  and  a  slight  eleva- 
tion of  temperature.  Considerable  doses 
of  alcohol  cause  a  decline  in  temperature 
of  the  body,  which  is  even  more  marked 
when  fever  is  present,  except  in  patients 
in  whom  a  decline  of  temperature  does 
not  follow  in  doses  short  of  lethal.  This 
reduction  of  temperature  produced  by 
alcohol  is,  doubtless,  referable  to  the 
diminished  rate  of  tissue  metamorphosis, 
for  it  has  been  ascertained  that  the 
excretion  of  both  urea  and  carbonic  acid 
is  lessened  by  alcohol;  the  combustion 
of  the  nitrogenous  and  carbonaceous 
foods  is  retarded.  This  action  results  in 
an  increase  of  body-weight,  as  seen  in 
the  rotundity  of  those  who  take  spirits 
moderately. 

The  action  of  alcohol  on  the  heart  is 
most  important.  When  the  heart  is 
weakened  by  debilitating  diseases  (pulse 
always  quick  and  weak),  it  strengthens 
the  contractions  and,  by  its  tonic  influ- 
ence on  the  heart,  alcohol  strengthens 
the  pulse  and  reduces  its  frequency.  It 
stands  first  as  a  safe  and  efficient  cardiac 
stimulant. 

Cases  in  which  it  is  contra-indicated: 
endocarditis,  pericarditis,  meningitis,  epi- 
lepsy, eclampsia,  chorea,  acute  diseases 
of  the  skin  and  certain  chronic  forms  (as 
eczema,  psoriasis,  etc.),  nodular  rheuma- 
tism, and  the  gouty  diathesis.  Jules 
Simon  (Med.  Age,  July  25,  '90). 

Alcohol  ought  to  be  given  very  spar- 
ingly, indeed,  to  people  with  chronic  car- 
diac disease,  and  one  great  consideration 
is  that,  having  once  begun  to  give  it  in 
such  cases,  it  is  very  difficult,  if  not  im- 
possible, to  leave  it  off.  It  is  obnoxious 
in  that  it  tends  to  diminish  the  desire  for 
food,  and  perhaps  may  actually  aggra- 
vate the  tendency  to  induration,  arterial 
and  valvular,  which  already  exists.  Al- 
cohol should  certainly  be  sparingly 
given.  Sidney  Coupland  (Clinical  Jour., 
Mar.  21,  '94). 

The  condition  of  the  svstem  causes 


great  variation  in  the  physiological  ef- 
fects of  alcohol.  In  convalescence  from 
acute  diseases,  in  the  condition  of  shock 
from  serious  injury,  loss  of  blood,  or 
snake-bites,  quantities  which  would,  un- 
der normal  conditions,  cause  intoxica- 
tion, are  taken  with  impunity. 

The  extremes  of  life  (infants  and  the 
aged)  bear  alcohol  well.  Habitual  use 
modifies  more  decidedly  the  influence  of 
alcohol  on  temperature,  circulation,  and 
the  nervous  system. 

In  the  diseases  of  childhood  all  forms 
of  gastro-intestinal  disturbance  can  be 
excluded  from  the  list  of  diseases  in 
which  alcohol  is  beneficial.  In  acute 
eases,  even  in  cholera  infantiim,  large 
quantities  of  water  with  a  small  amount 
of  black  coffee  or  tea  will  stimulate  better 
than  alcohol,  while  it  is  not  irritating  to 
the  already  diseased  mucous  membrane. 
It  is  especially  irrational  and  harmful 
to  administer  alcohol  in  the  diarrhoeas 
of  children  before  the  stomach  and  bow- 
els have  been  freed  from  all  putrefying 
material. 

In  the  typhoid  fever  of  childhood 
Seibert  rarely  gives  alcohpl.  The  disease 
usually  runs  a  mild  course  and  relapses 
seldom  occur  if  proper  diet  is  adhered  to. 
In  pneumonia  the  enormous  quantities 
of  alcohol  which  are  frequently  given 
are  irrational;  they  should  only  be  used 
when  collapse  threatens  or  is  present, 
and  then  in  large  doses  and  in  concen- 
trated form.  Alcohol-fed  children  digest 
less  perfectly  in  pneumonia  than  others, 
and  do  not  regain  their  appetite  and 
digestive  power  after  the  attack  is  over 
as  those  do  who  are  treated  without  it. 

Alcohol  prepared  in  the  form  of  pen- 
cils, for  the  treatment  of  superficial  im- 
petigo, sycosis  with  small  pustules, 
pustular  acne,  and  pustular  rosacea. 
The  patient  carries  the  pencil  with  him, 
wrapped  in  tin-foil,  and  is  instructed  to 
rub  it  over  the  papules  and  pustules  as 


ALCOHOL. 


ALCOHOLIC  NEURITIS. 


193 


frequently  as  possible.     The  formula  for 
the  pencils  is  as  follows: — 

IJ  Sodium  stearate,  G  grammes. 
Glycerin,  25  grammes. 
Alcohol,  100  grammes. 

The  glycerin  is  added  to  prevent  brit- 
tleness.  P.  G.  Unna  (Monats.  f.  prakt. 
Dermat.,  xxxi.  No.  11,  1900). 

C.  Sumner  Witherstine, 

Philadelphia. 

ALCOHOLIC  NEURITIS. 

Definition.  —  Inflammation  of  the  pe- 
ripheral nerves,  especially  those  of  the 
extremities,  due  to  the  excessive  use  of 
alcohol. 

Symptoms.  —  The  first  symptom  of 
alcoholic  neuritis  consists  usually  in  neu- 
ralgic and  tingling  pain,  especially  in  the 
lower  limbs,  less  commonly  in  the  upper 
limbs.  Long  prior  to  these  first  painful 
sensations  there  generally  are  feelings  of 
debility,  lethargy,  anorexia,  or  uneasi- 
ness, with  disturbed  sleep.  The  sufferer 
labors  under  malaise,  cannot  tell  what 
is  the  matter,  and  rarely  seeks  medical 
advice  till  the  pains  become  severe. 

Alcoholic  paralysis  of  the  upper  limb 
usually  affects  the  muscles  animated  by 
the  mnsciilo-spiral  nerve,  and  is  often 
complete,  which  is  the  opposite  of  what 
is  usually  seen  in  plumbism. 

Wrist-drop  and  foot-drop  occur  from 
the  extensors  being  more  affected  than 
the  flexors.  The  facial  muscles  and  the 
sphincters  may  be  affected  in  very  rare 
■cases.  These  pains  are  usually  followed 
by  difficulty  in  walking,  which  in  turn 
is  due  to  paresis  of  the  leg-muscles  and 
ataxia. 

A  distinctive  walk,  called  the  high- 
stepping,  or  pseudotabetic,  gait,  consists 
in  raising  the  foot  and  throwing  it  for- 
ward, the  toes  hanging  down  causing  the 
patient  to  raise  the  heel,  the  sole  being 


visible  from  behind.  This  "high-step- 
ping" is  seen  only  when  foot-drop  is 
distinct.  It  resembles  the  gait  of  a  man 
meeting  obstacles  while  walking. 

When  the  lower  limb  is  affected,  and 
when  the  patient  is  lying  down,  the  foot 
forms  an  obtuse  angle  with  the  leg,  its 
outer  edge  is  lower  than  the  inner,  and 
the  phalanges  are  fixed.  The  patient 
cannot  move  his  toes  or  raise  the  outer 
edge  of  the  foot.  The  foot  can  be  ex- 
tended on  the  leg,  but  only  slightly 
flexed  on  it.  Usually  the  paralysis  be- 
gins by  the  extensor  proprius  hallucis, 
followed  by  the  extensor  communis  and 
the  peronei;  the  quadriceps  may  be  also 
affected,  and  may  indeed  be  the  only 
muscle  paralyzed.     (J.  Babinski.) 

Two  cases  of  paralysis  of  the  left  vocal 
cord  due  to  alcoholic  neuritis.  In  the 
first  case  there  had  been,  for  fifteen  days, 
such  a  feebleness  of  voice  that  the  pa- 
tient, a  clergyman,  was  unable  to  fulfill 
his  duties.  There  was  no  thoracic  affec- 
tion and  no  sign  of  locomotor  ataxia. 
The  left  vocal  cord  was  ir.  the  cadaveric 
position.  The  patient  gave  a  history  of 
recent  sciatica  in  the  left  leg,  but  ac- 
companied also  by  a  pronounced  anaes- 
thesia of  that  member.  The  patient, 
although  never  drunk,  was  accustomed 
to  drink  a  quart  of  strong,  English  beer 
at  luncheon  and  dinner,  and  in  the  even- 
ing a  considerable  quantity  of  brandy. 
Complete  abstinence  was  enjoined  and 
carried  out,  and  fairly  large  doses  of  nux 
vomica  prescribed.  By  the  end  of  four 
weeks  the  voice  had  completely  returned 
and  the  vocal  cord  had  regained  its  nor- 
mal functions.  Dundas  Grant  (Archives 
de  Laryng.,  May,  June,  '97). 

Later  on,  atrophy  of  the  muscles  may 
be  noted,  supplemented  sometimes  by 
degeneration  reaction  to  electricity.  The 
knee-jerk  is  lost  early  in  the  history  of 
the  case.  The  hands  and  feet  may  be- 
come swollen  and  congested  when  al- 
lowed to  hang  down. 

AuEesthesia  of  the  legs,  and  even  of 


194 


ALCOHOLIC  NEURITIS.    DIAGNOSIS. 


other  portions  of  the  body,  is  frequent. 
Indeed,  disturbances  of  the  sensibility 
may  be  noted  when  motor  disturbances 
are  of  little  importance;  the  opposite, 
however,  does  not  occur.  On  the  other 
hand,  parsesthesia  may  be  present,  press- 
ure on  the  muscles  and  nerves  causing 
great  pain.  Cutaneous  reflexes  are  some- 
times diminished  in  extent  and  rapidity. 

Convulsions  and  fever  rarely  occur. 
Mental  symptoms  are  occasionally  pres- 
ent, but  they  are  frequently  slight, 
amounting  only  to  irritability,  unrest, 
and  suspicions. 

In  a  proportion  of  cases  there  are 
delirium  and  extravagant  hallucinations 
resembling  those  of  general  paralysis,  the 
most  characteristic  being  a  loss  of  appre- 
ciation of  time  and  place.    (Wilks.) 

Eecent  events  are  forgotten,  while 
ancient  ones  are  remembered.  The  ocu- 
lar disturbances  of  alcoholism  are  bilat- 
eral, symmetrical,  and  affect  both  eyes 
equally.  They  chiefly  consist  in  a  cen- 
tral scotoma,  ellipsoid  in  shape,  with  the 
longer  axis  horizontal;  red  and  green 
are  the  first  colors  not  seen.  Ophthal- 
moscopically,  the  temporal  side  of  the 
disk  is  discolored.  Paralysis  of  the  motor 
externus,  ptosis,  and  external  ophthal- 
moplegia have  been  noted.  The  pupils 
may  react  more  slowly  than  normally  to 
light.    (J.  Babinsld.) 

Diagnosis. — Eheumatic  pains  in  the 
early  stages.  The  failure  of  sodium 
salicylate  to  alleviate  the  pain,  with  the 
temporary  lull  from  opiates,  though  the 
pains  thereafter  persist,  soon  excludes 
rheumatism. 

General  Paeesis. — It  can  be  differ- 
entiated from  this  disease  by  the  absence 
of  paralysis  of  the  tongue  and  lips  and  of 
grandiose  delusions,  by  the  presence  of 
muscular  wasting  with  wrist-  and  foot- 
drop,  by  the  tearing  or  stabbing  pains, 
by  the  lost  knee-jerk,  extreme  pain  on 


pressure,  and  by  a  feeling  of  coldness  on 
being  touched. 

Alcoholic  paralysis  is  the  disease  most 
frequently  mistaken  for  general  paraly- 
sis.    An  important  differential  point  is 
the  mode  of  development  of  each  disease, 
general  paralysis  always  commencing  in- 
sidiously,  alcoholic   paralysis   frequently 
Avith  great  suddenness,  and  it  is  believed 
that  this  sudden  development,  associated 
with  the  pen'ersion  of  the  affections,  is 
almost  sufficient  to  confirm  the  diagnosis. 
These   features   have   also   been   insisted 
upon  by  Charpentier.    E.  JI.  de  Montyel 
(Eevue  de  Med.,  Feb.  10,  '98). 
LocoMOTOE  Ataxia.  —  In  this  affec- 
tion there  are  girdle  pains;   urinary  and 
ocular  disturbances  are  almost  constant, 
while    atrophic   paralysis   belongs   more 
especially  to  alcoholic  neuritis.    In  non- 
alcoholic locomotor  ataxia  the  toes  are 
raised,  but  in  alcoholic  neuritis  they  hang 
down.     The  non-alcoholic  comes  down 
on  his  heel,  the  alcoholic  neuritic  on  his 
toes.    The  paralysis  of  the  former  is  not 
so  symmetrical  and  his  gait  is  more  un- 
even and  jerky  than  the  latter. 

Lead  Paealysis. — It  may  be  differ- 
entiated from  this  disorder  by  the  ab- 
sence of  the  blue  gum-line,  and  by  the 
much  greater  prospect  of  recovery. 

Disseminated  Sclerosis. — This  dis- 
ease can  be  eliminated  by  the  absence  of 
head  rhythmical  tremors,  spastic  paraly- 
sis, and  hyperalgesia,  which  occur  in 
alcoholic  paralysis  with  nystagmus. 

From  special  ateophic  paralysis 
by  the  absence  of  pain  in  the  non-alco- 
holic. From  Landry's  acute  ascending 
paralysis  by  tue  legs  being  affected  first, 
the  arms  next,  and  then  the  trunk  (if  at 
all),  and  the  foot-drop,  there  being  no 
foot-drop  in  Landry's,  and  in  the  latter 
the  trunk  being  affected  immediately 
after  the  legs;  besides,  Landry's  has  no 
muscular  atrophy  and  no  alcoholic  elec- 
trical reaction  of  degeneration. 

From   PEOGEESSIVE   musculae   ateo- 


ALCOHOLIC  NEURITIS.     ETIOLOGY.     PATHOLOGY. 


195- 


PHY  by  the  presence  of  pain  and  the 
alcoholic  degeneration  reaction;  so  also 
from  chronic  anterior  poliomyelitis. 

From  TOXIC  htstekical  paralysis 
by  the  suddenness  of  the  hysterical  onset 
and  cessation. 

From    CEHEBEAL   HEMIPLEGIA   in    that 

hemiansesthesia  is  rarely  met  with  in 
that  disease.  From  various  nervous 
affections  of  a  mixed  character. 

Etiology. — Alcoholic  neuritis  is  more 
common  in  women,  and  in  those  who 
have  drunk  quietly  for  a  long  time.  It 
is  especially  due  to  the  inordinate  use 
of  spirits  and  alcoholized  wines,  such  as 
sherry,  Madeira,  etc. 

One  hundred  and  twenty  cases  of  al- 
coholic nervous  affections,  of  which  only 
nineteen  could  be  classed  as  polyneu- 
ritis. The  motor  form  was  the  more  fre- 
quent, and  the  ataxic  second.  Freyhan 
(Deutsches  Arch.  f.  klin.  Med.,  vol.  li,  p. 
6,  '94). 

Child,  3  V2  years  old,  who,  after  a  large 
drink  of  whisky,  went  into  stupor  vaiy- 
ing  in  depth  and  lasting  more  than  two 
months;  had  a  large  number  of  convul- 
sions, partly  general  and  partly  limited 
to  the  left  side;  developed  right-sided 
paralysis,  which  was  especially  marked 
in  the  arm;  extreme  contractures,  espe- 
cially of  the  left  side,  and  loss  of  faradic 
irritability  with  wasting,  and  during  the 
first  two  months  had  pupillary  symp- 
toms, strabismus,  and  repeated  vomiting. 
During  six  weeks  there  were  the  signs  of 
complete  consolidation  of  the  right  lower 
lobe.  Recovery.  Herter  (N.  Y.  Med. 
Jour.,  Nov.  7,  '96). 

Case  of  alcoholic  multiple  neuritis  fol- 
lowing prolonged  debauch.  In  the  spinal 
cord  very  marked  lesions  were  found  in 
the  anterior  horns,  the  posterior  horns, 
the  columns  of  Clarke,  and  the  nucleus 
of  Stilling,  and  in  the  ganglion-cells,  the 
changes  being  especially  marked  by  their 
great  variety.  The  most  common  was 
central  chromatolysis.  There  were  also 
distinct  degenerative  changes  in  the  cor- 
tex of  the  brain.  Fatal  alcoholic  mul- 
tiple neuritis  causes  grave  changes  in  the 


ganglion-cells  characterized  by  extreme- 
polymorphism.  J.  H.  Larkin  and  Smitb 
Ely  Jelliffe   (Med.  Record,  July  8,  '99). 

Pathology.  —  Until  recently  (1881), 
when  Clarke  discovered  a  softening  of 
certain  portions  of  the  spinal  tissue,  the 
post-mortem  appearances  seen  had  been 
peripheral.  Eichhorst  found  a  few  dis- 
eased patches  in  the  middorsal  region 
besides  disease  of  smaller  vessels  through- 
out, and  increase  of  the  connective  tissue 
in  the  lateral  column.  Schafer,  Paj'ne, 
and  Sharkey  found  ganglionic  inflam- 
matory changes  and  degeneration.  Pal 
noted  degeneration  of  Lissauer's  poste- 
rior root-zone  in  the  lumbar  region  and 
general  involvement  of  Goll's  columns; 
in  another  case  degeneration  of  GoU's 
columns  in  cervical  region,  less  marked 
in  the  dorsal,  appearing  again  in  the 
lumbar.  Thomson  found  disease  of  the 
nuclei  of  some  of  the  cranial  nerves  in 
the  pons  and  medulla  oblongata.  Hun 
and  Kojewnikoff  observed  slight  degen- 
erative changes  in  the  ganglion-cells  of 
the  cortex  cerebri.  Dejerine  and  Sharkey 
have  described  disease  in  the  vagi  and 
phrenic  nerves.  Congestion  of  pia  mater 
has  been  noted.  Campbell  also  noted 
these  ("Trans.  Path.  Sec.  Liverpool  Med. 
Inst.,"  vol.  xsiii,  No.  2,  '"93).  The  prin- 
cipal changes  have  been  met  with  in  the 
periphery,  generally  limited  to  the  finer 
nerve-terminations,  the  morbid  intensity 
diminishing  with  the  distance  from  the 
periphery.  These  degenerative  changes 
are  generally  symmetrical  in  the  upper 
and  lower  limbs,  the  latter  being  most 
frequently  involved.  This  peripheral  in- 
flammatory degeneration  is  parenchyma- 
tous, the  iniiammatory  process  being 
secondary  to  strangulation  of  the  nerves 
higher  up.  Sometimes  the  part  affected 
is  swollen;  at  other  times  the  microscope 
alone  reveals  the  lesion,  disclosing  a  dull 
appearance  from  fatty  myeline  degener- 


196 


ALCOHOLIC  NEURITIS. 


ALCOHOLISM. 


ation.  The  degenerated  cloudy  portion 
gradually  separates  till  the  segments 
surround  the  axis-cylinder  as  fatty  par- 
ticles. In  the  sheath  and  intestinal 
tissues  there  is  a  great  increase  of  the 
nuclei  of  the  sheaths  and  infiltration 
with  leucocytes,  with  thickening  of  the 
perineurium.  Finlay  found  wasting  of 
the  fibres  of  the  wrist  extensors,  leu- 
cocytes and  nuclei  crowding  the  inter- 
stitial spaces.  In  peripheral  neuritis  are 
found  peripheral  lesions;  in  alcoholic 
insanity  and  dementia  the  lesions  are 
central:  brain  shrinkage  and  softening, 
shallowing  of  interconvolutional  fur- 
rows, tortuous  atheromatous  vessels,  and 
ventricular  eflEusion. 

In  the  optic  nerves  the  interstitial 
tissue  is  first  affected;  there  are  found 
many  healthy  fibres,  which  is  the  oppo- 
site of  what  occxirs  in  the  optic  neuritis 
-of  locomotor  ataxia,  and  which  explains 
the  clinical  aspect  of  alcoholic  ambly- 
opia. 

Most  important  effects  of  alcohol  on 
the  tutular  neurin  are  shrinking  and 
hardening,  transmission  of  impulses  being 
impaired;  on  vesicular  neurin  the  disso- 
lution of  phosphorus,  protagon,  and  lec- 
ithin, with  selective  affinity  for  the 
neurin  of  the  cerebellum.  Wilkins  (N.  Y. 
Med.  Jour.,  Sept.  22,  '94). 

[Statement  as  to  hardening  of  the 
neurin  and  other  tissues  by  alcoholic  in- 
gestion requires  further  corroboration. 
Frequently  microscopical  appearances  are 
deceptive.  Norman  Kerr,  Assoc.  Ed., 
Annual,  '96.] 

Prognosis.  —  Complete  recovery  may 
be  obtained  in  the  great  majority  of 
cases  if  alcohol  be  completely  renounced. 
In  very  grave  cases,  especially  when  the 
patient  is  not  seen  in  time,  total  paral- 
ysis, and  even  death,  may  supervene. 
The  amyatrophy  of  alcoholic  neuritis 
may  become  extremely  marked,  and  end 
in  the  formation  of  fibrotendinous  re- 
tractions. 


Treatment.  —  Alcohol  must  be  given 
up  at  once  and  always.  Electrotherapy; 
cold,  tepid,  hot,  or  Turkish  baths; 
sponging,  and  strychnine  preparations 
are  recommended.  So  also  are  arsenic, 
nux  vomica,  cinchona,  and  the  iodides. 
The  food  must  be  easily  assimilable. 

Alcoholic  paraplegia  in  a  woman  30 
years  old,  who  was  completely  cured  by 
combined  galvanization  of  the  spinal  cord 
and  the  paralyzed  muscles.  Later  fara- 
dization was  employed.  Massy  (Jour, 
de  Med.  de  Bordeaux,  Apr.  23,  '93). 
KOHIIAN   KeKE, 


ALCOHOLISM. 

Definition. — The  various  pathological 
changes  and  attendant  symptoms  caused 
by  the  ingestion  of  alcoholic  beverages. 

Varieties. — Two  forms  are  recognized: 
the  acute,  in  which  alcoholic  poisoning 
speedily  manifests  active  excitement  and 
disturbance,  or  in  which  a  sudden  ex- 
acerbation of  the  disorders  attending  the 
chronic  type  gives  rise  to  correspond- 
ingly marked  symptomatic  activity;  the 
chronic,  in  which  the  continued  ingestion 
of  alcoholic  beverages  in  more  or  less 
appreciable  quantities  sets  up  patholog- 
ical changes,  the  morbid  transformations 
gradually  involving  the  various  organs 
and  tissues  and  giving  rise  to  chronic 
disorders  of  each  of  the  parts  thus  at- 
tacked. 

The  older  denomination  of  "delirium 
tremens"  is  now  considered  under  the 
heading  of  "acute"  alcoholism,  as  are, 
also,  acute  alcoholic  poisoning,  intoxi- 
cation, acute  alcoholic  insanity,  acute 
alcoholic  paralysis  (alcoholic  neuritis 
and  alcoholic  toxic  hysterical  paralysis), 
acute  alcoholic  epilepsy,  etc.  To  make 
this  article  more  intelligible,  it  was 
deemed  best,  however,  to  adopt  the  fol- 
lowing subdivisions:  Acute  Alcoholic 
Intoxication,  drunkenness;  Acute  Al- 


ALCOHOLISM.    ALCOHOLIC  INTOXICATION.    ACUTE.     SYMPTOMS. 


i9r 


coHOLic  Delieium,  delirium  tremens; 
Acute  Alcoholic  Mania,  mania  a 
potii;  and  Cheonic  Alcoholism,  the 
meaning  of  which  has  already  been 
given. 

Acute  Alcoholic  Intoxication. 

Symptoms. — Three  stages  are  discern- 
ible in  this  condition.  The  first  is  vas- 
cular relaxation,  when  the  intoxicated 
is  usually  lively,  merry,  agile,  and  joy- 
ous; all  excitement  and  energy;  in  the 
highest  spirits,  cheerful,  hopeful,  and 
communicative;  mercurial  and  confid- 
ing, often  telling  his  private  affairs  to 
strangers.  There  is  a  warm  glow  of 
color  on  his  countenance,  he  looks  at 
his  best.  Gradually  his  spirits  rise  still 
higher;  he  becomes  more  demonstrative 
in  love  or  in  argument,  more  emphatic 
in  his  gestures,  more  furious  in  his  fun, 
and  very  much  louder  in  his  laughter, 
as  the  second  stage  is  ushered  in.  With 
this  he  is  becoming  much  less  reasonable 
and  amenable,  incoherence  of  thought 
and  speech  gradually  set  in,  the  imagina- 
tion revels,  exaggeration  is  a  prominent 
feature,  and  his  emotions  dominate  him, 
intellect,  reason,  will,  and  conscience 
rapidly  fading  in  the  background.  In 
some  cases  his  thoughts,  speech,  and 
actions  are  exaggerated.  In  other  cases 
these  are  transformed,  the  usually 
modest,  retiring  man  becoming  a  boaster 
and  a  braggart,  the  truthful  a  liar,  the 
meek  violent.  With  all  this,  speech 
thickens,  the  lower  and  then  the  upper 
limbs  cease  to  act  in  unison,  the  intoxi- 
cated cannot  stand,  but  staggers  with 
paralytic  drunken  unsteadiness  of  gait, 
the  muscles  becoming  flabby  and  feeble. 
The  third  stage  of  "dead  drunkenness" 
reveals  an  unconsciousness  with  the 
pallor  of  apparent  death  on  the  face, 
extreme  coldness,  accompanied  by  total 
insensibility  and  an  utter  disregard  of 
the    "world    without"    and    the    "world 


within."  Sensation,  perception,  volition, 
and  emotion,  all  are  absent.  Through 
this  living  death  in  the  heart  and  cir- 
culation lingers  the  only  spark  of  vitality 
which  keeps  the  unconscious  drunkard 
just  alive  till  the  faculties,  if  they  do 
emerge,  have  emerged  from  the  depth  of 
narcotism  into  which  they  were  plunged. 
In  some  cases  the  first  pleasurable  stage 
and  the  second,  less  pleasant,  may  vary 
in  intensity  and  duration,  but  the  last 
insensible  stage  usually  lasts  from  six  to 
twelve  hours.  These  successive  groups 
of  symptoms,  or  stages,  may  be  described 
as  "the  three  acts  of  the  drama  of  in- 
toxication." 

Alcoholic  acute  poisoning  is  some- 
times manifested  as  epileptic  explosions. 
These  are,  in  some  cases,  with  a  known 
epileptic  neurosis,  the  indirect  effect  of 
alcoholic  provocation;  but  there  are 
other  cases  in  which  acute  alcoholic 
excitation  seems  to  directly,  after  a  cer- 
tain cjuantity  of  poison  has  been  taken, 
set  up  epileptic  seizures  (these  seizures 
appearing  only  after  the  ingestion  of 
alcohol),  in  which  cases  no  epileptic  at- 
tacks or  tendencies  are  ever  observed  so 
long  as  alcohol  is  not  drunk.  Purely 
hysterical  paroxysms  are  also  excited  in 
some  cases  by  the  consumption  of  even 
small  doses.  Some  of  the  subjects  so  apt 
to  be  toxically  affected  in  this  way  never 
display  hysterical  symptoms  at  other 
times. 

Etiology. — Though  the  toxic  action  of 
alcohol  in  the  causation  of  alcoholic  in- 
toxication is  the  same  in  kind,  all  kinds 
of  alcohols  being  poisonous,  the  toxic 
action  is  modified,  in  a  minor  degree  (1) 
by  the  variety  of  the  alcohol;  (2)  by 
the  idiosyncrasy  of  the  drinker.  The 
heavier  and  less  highly  rectified  spirits 
(anlylic  and  butylic)  are  more  toxic 
than  the  lighter  (ethylic  and  methylic). 
Spirits  are  more  acutely  toxic  than  equal 


198 


ALCOHOLISM.    ALCOHOLIC  INTOXICATION.    ACUTE.     PATHOLOGY. 


quantities  of  wines  and  beers,  from  the 
greater  concentration  and  quantity  of 
the  alcohol  in  the  former,  tending  more 
intensel}'  to  acute  congestion  and  irrita- 
tion of  the  gastric  mucous  membrane,  the 
liver,  kidney,  heart,  and  brain.  Absinthe 
induces  epileptic  convulsions;  and  meth- 
ylism  is  miieh  more  rapid  in  its  course 
than  ethylie  alcohol.  The  temperament 
and  constitution  of  the  drinker  also  oc- 
casion some  difference  of  symptoms,  one 
subject  getting  drunk  at  once  "in  the 
legs,"  another  "in  the  tongue." 

In  dogs  wine-alcohol  produces  depres- 
sion and  inebriety  lasting  four  to  five 
hours;  beet-root  alcohol,  comatose  sleep 
and  anossthesia  lasting  twenty-four 
houi's,  followed  by  illness;  maize-alco- 
hol, the  same  plus  subsultus  tendinum. 
Magnan  (Le  Bull.  Med.,  July  31,  '95). 

Of  all  alcoholic  drinks  the  most  dan- 
gerous are  the  liquors  containing  essen- 
tial oilSj  such  as  the  various  absinthes 
and  anisettes.  The  least  harmful  are 
those  made  without  essential  oils — 
from  chemically-pure  industrial  alcohol, 
brandy,  bitters,  etc.^=— by  means  of  non- 
toxic flavoring  materials.  For  an  iden- 
tical proportion  of  alcohol,  wines  are 
more  toxic  than  wine-brandies^  which, 
in  turn^  are  more  toxic  than  brandies 
artificially  prepared  by  means  of  well- 
rectified  commercial  alcohol.  Generally 
white  wines  are  less  toxic  tlian  red  wines. 
Wines  treated  with  plaster  and  diseased 
wines  are  exceedingly  toxic.  Experi- 
ments made  by  means  of  intravenous  in- 
jections in  rabbits  demonstrating  the 
above.  Daremberg  (Archives  de  Med. 
Expgr.,  vol.  vii,  p.  6,  '95). 

Drinking  habits  existed  in  one  or  both 
parents  in  all  of  350  cases  examined  ex- 
cepting 10.  The  father  was  usually  the 
drinker.  In  another  series  of  210  cases 
the  percentage  was  much  lower:  25  per 
cent,  gave  a  negative  hereditary  history. 
Mechanics,  artisans,  and  small  trades- 
men furnish  the  greatest  proportion  of 
cases,  the  in-door  workman  being  often- 
est  the  victim.  About  one-third  of  in- 
ebriates are  women.  C.  L.  Dana  (Med. 
Record,  July  27,  1901). 


Pathology.  Post-mortem  Appearances. 

— In  a  fatal  case  seen  by  me,  of  a  mar- 
ried woman,  aged  41,  who  had  died 
mthout  recovering  consciousness  in  5  ^/^ 
hours  after  swallowing  at  a  draught  2  ^/^ 
piints  of  whisky,  the  face  was  pale,  the 
eyes  suffused  and  dull  with  dilated 
pupils,  the  temperature  91°  F.;  the  ptilse 
was  thin,  compressible,  and  barely  per- 
ceptible; the  breathing  stertorous,  the 
skin  cold  and  clammy.  There  are  some- 
times also  congestion  of  the  liver,  cere- 
bral congestion  with  ventricular  serous 
effusion,  and  distension  of  right  heart- 
cavities  with  semifluid  blood.  In  another 
case,  that  of  a  man  who  was  found  dead 
after  a  drinking-bout,  the  mucous  mem- 
brane of  the  stomach  was  so  inflamed 
and  angr}^,  with  patches  of  a  deeper  hue 
extending  over  the  pyloric  surface  to 
the  duodenum,  and  a  grumous,  slightly 
muco-puruleut  exudation  from  bleeding- 
points,  that  arsenical  poisoning  was  sus- 
pected. Tardieu  in  one  case  found 
pulmonary  .  apoplectic  extravasations  of 
blood. 

The  first  pathological  stage  of  intoxi- 
cation is  one  of  vascular  relaxation,  with 
vasomotor  paral3'sis  and  reduced  inhi- 
bition; the  second,  one  of  continued 
inhibitory  reduction,  with  incomplete 
partial  paralysis  of  the  brain-  and  nerve- 
centres,  with  intellectual  automatism, 
accompanied  by  loss  of  co-ordination. 
The  third  stage  is  one  of  advanced  pa- 
ralysis, for  the  moment  complete,  with 
automatic  existence  and  the  reduction 
of  temperature  by  3  to  7  or  more  degrees. 

Poisoning  with  alcohol  in  considerable 
doses,  continued  over  a  moderate  time, 
will  produce  decided  and  ascertainable 
lesions  of  the  nutrient  structures  and 
nervous  elements  of  the  cerebrum,  very 
similar  in  character  to  the  pathological 
lesions  produced  by  other  more  virulent 
soluble  poisons.  Henry  J.  Berkley  (.Johns 
Hopkins  Hosp.  Keports,  vol.  vi,  '97). 


ALCOHOLISM.    ALCOHOLIC  INTOXICATIOX.    ACUTE.    DIAGNOSIS. 


199 


Differential  Diagnosis.  —  In  the  first 
two  stages,  the  exhilarative  and  the 
preliminary  automatic,  simple  nerve  ex- 
citement, opiate  or  other  narcotic  excita- 
tion, and  apoplexy  may  simulate  the 
symptoms  of  alcoholic  intoxication;  but 
the  non-alcoholic  rapidly  subside,  the 
apoplectic  either  passing  ofE  or  going  on 
quickly  to  coma.  Usually  the  history  or 
the  surroundings  reveal  the  presence  of 
alcohol. 

In  the  last,  or  third,  stage  of  alcoholic 
insensibility  the  difficulties  are  much 
greater.  The  breath  may  smell  of  liquor, 
but  that  alone  is  not  a  safe  guide;  I  have 
known  abstainers  taken  to  a  police-cell, 
owing  to  some  by-stander  having  poured 
brandy  down  the  throat  of  the  uncon- 
scious nephalist.  Apart  from  a  history 
of  drinking,  only  withdrawal  of  alcohol 
from  the  stomach  can  prove  an  alcoholic 
origin.  It  has  been  asserted  that  press- 
ure on  the  supra-orbital  notches,  thereby 
compressing  the  nerve,  will  elicit  signs  of 
life  in  the  alcoholized. 

Coma. — The  comatose  state  of  diabetes 
and  albuminuria  (in  ursemia  there  may 
be  albuminuric  retinitis  "with  normal  or 
enlarged  pupils)  may  be  differentiated 
by  a  urinary  analysis,  though  it  must  be 
remembered  that  both  of  these  condi- 
tions may  exist  with  alcoholism,  and  also 
with  the  odor  of  acetone  from  the  breath. 
The  renewal  of  the  alcoholic  symptoms 
by  inhalation  of  the  vapor  of  ammonia 
has  been  suggested  by  Waters. 

Opium  or  Belladonna  Poisoning. — 
From  opium  poisoning,  pin-point  pupils, 
and  from  belladonna  poisoning,  the  equal 
dilation  of  the  pupils  usually  exclude 
alcoholism,  but  alcohol  may  be  present 
with  either  of  the  other  poisons.  Some- 
times the  greatly  lowered  temperature 
points  to  alcoholism. 

Apoplexy. — The  respiration  is  usually 
stertoroiis  and  the  coma  deeper.    Hemi- 


plegia may  be  evident  from  the  greater 
flaccidity  of  the  limbs  on  one  side.  The 
urine  may  contain  albumin;  ausculta- 
tion may  reveal  some  cardiac  lesion;  the 
breath  will  not  smell  of  alcohol,  unless 
the  attack  has  occurred  in  a  person  who 
has  been  drinking,  or  some  one,  since 
the  attack,  has  administered  some  alco- 
holic stimulant.  Conjugate  deviation  of 
the  eyes  may  exist. 

Epilepsy. — In  this  disease  there  is  a 
history  of  clonic  convulsions.  The  pulse 
is  rapid,  dicrotic  (Trousseau),  and  rather 
fast;  frequently  the  urine  and  faeces 
have  escaped,  while  the  tongue  may  have 
been  bitten. 

The  frequent  mistakes  in  diagnosis 
committed  by  medical  experts  have  dem- 
onstrated the  practically  insuperable  dif- 
ficulty in  forming  an  accurate  judgment 
till  time  be  given  for  the  disappearance 
of  alcoholic  symptoms.  "For  a  time  it 
may  be  impossible  to  determine  whether 
the  condition  is  due  to  ursmia,  profound 
alcoholism,  or  hsemorrliage  into  the  pons 
Varolii." 

Diagnosis  between  acute  alcohoUsm 
and  traumatism:  external  injury  sug- 
gests the  possibility  of  grave  internal 
lesion.  However,  no  mark  of  violence 
may  be  found  upon  the  closest  inspec- 
tion; a  fracture  of  the  skull  or  a  hem- 
orrhage within  the  cranium  may  have 
no  outward  sign.  Or  a  heavy  wagon  may 
pass  over  the  body,  fracturing  the  ribs, 
rupturing  the  liver,  perforating  the  in- 
testines, or  injuring  other  vital  organs 
without  producing  any  external  mark. 
(See  Abdomen,  Contusions.)  Primary 
shock,  following  immediately  upon  the 
injury,  will  exhibit  a  subnormal  tempera- 
ture and  a  small  and  fluttering  pulse, 
nausea,  vomiting,  cold  and  clammy  skin, 
and  relaxed  sphincters. 

Depressed  fractures  at  the  vertex  may 
be  detected  by  palpation.  Fissured  fract- 
ures may  be  found  upon  inspection,  with 
the  help  of  an  incision  if  necessary,  or 
the  finger-nail  or  a  probe  may  be  passed 


200 


ALCOHOLISM.    ALCOHOLIC  INTOXICATION.    ACUTE.    TEEATMENT. 


across  the  surface.  When  the  blood  is 
wiped  from  a  suspected  part  and  no  fresh 
blood  appears,  there  is  a  suture;  if  fresh 
blood  oozes  to  the  surface,  there  is  a  fis- 
sured fracture.  In  fracture  of  the  base 
there  will  usually  be  found  haemorrhage 
from  the  nose,  mouth,  and  ears,  and 
eechymosis  into  the  conjunctiva  or  sub- 
cutaneous cellular  tissue;  or  vomited 
blood  may  have  been  swallowed  after 
fracture  of  the  ethmoid  or  sphenoid,  fol- 
lowed by  hseniorrhage  into  the  posterior 
nares.  But  absence  of  such  haemorrhage 
does  not  necessarily  indicate  absence  of 
fracture. 

A  rare,  but  positive,  symptom  of  fract- 
ure of  the  base  is  the  escape  of  a  watery 
fluid,  probably  cerebro-spinal  fluid,  from 
the  ears,  the  nose,  or  the  mouth.  Fract- 
ures of  the  petrous  portion  of  the  tem- 
poral bone  involving  the  tympanum  may 
produce  in  the  temporal  or  mastoid  re- 
gion a  pneumatocele:  a  smooth,  circum- 
scribed, resonant,  non-fluctuating  tumor. 

Cerebral  irritation  usually  follows  a 
blow  upon  the  forehead  or  the  temple. 
The  patient  lies  on  one  side,  is  restless, 
with  the  extremities  flexed  and  the  eye- 
lids firmly  closed.  If  the  eyelids  are 
forcibly  opened,  the  pupils  are  found  con- 
tracted and  intolerant  of  light.  The  sur- 
face is  pale  and  cool,  or  even  cold.  The 
pulse  is  small,  feeble,  and  slow.  The 
patient  is  irritable,  muttering,  and  grinds 
his  teeth  when  disturbed.  The  sphincters 
are  not  usually  afi'ected  and  thei'e  is  no 
stertor. 

There  will  be  a  rise  in  temperature  iu 
head  injuries,  except  in  primary  shock 
and  in  large  uncomplicated  haemorrhage, 
when  the  temperature  is  likely  to  be  sub- 
normal (Phelps).  Other  signs  of  intra- 
cranial lesion  are  photophobia,  with  the 
eyelids  firmly  closed,  intolerance  of 
sound,  the  carotids  beating  forcibly,  a 
blowing  of  the  lips,  a  flapping  of  the 
cheeks,  rigid  contraction  of  limbs,  and 
clonic  or  tetanic  convulsions.  The 
Cheyne-Stokes  respiration  is  found  in 
injury  to  the  brain  and  cerebral  haemor- 
rhage. The  breathing  becomes,  by  de- 
grees, deeper  and  more  rapid  up  to  a  cer- 
tain point,  and  then  subsides  in  the  same 
gradual  manner  until  there  is  a  complete 


cessation  of  respiration,  with  a  deep 
silence,  the  pause  before  the  next  respira- 
tion lasting  a  variable  time. 

Unilateral  phenomena  point  to  in- 
tracranial lesions;  for  instance,  unequal 
pupils  or  ptosis  of  one  eyelid  or  drooping 
of  one  corner  of  the  mouth.  There  may 
also  be  found  in  the  radial  pulse  a  want 
of  symmetry  in  fullness  and  strength 
upon  the  two  sides  of  the  body. 

•  In  a  suspected  case  the  patient  should 
be  kept  under  observation  until  the 
efi'ects  of  a  debauch  have  worn  off; 
symptoms  of  head  injury,  which  may 
have  been  masked  by  the  acute  alcohol- 
ism, may  then  become  manifest.  John 
B.  Huber  (Med.  Record,  Feb.  20,  '97). 

Quinquaud's  sign  of  alcoholism:  The 
patient  is  to  separate  the  fingers  and  rest 
them  firmly  across  the  observer's  hand 
at  right  angles.  For  the  first  two  or 
three  seconds  nothing  unusual  is  noted, 
but  then  follow  slight  blows  as  if  the 
bones  of  each  finger  were  thrown  back 
suddenly,  the  one  upon  the  other,  and 
struck  the  palm.  The  crepitations  vary 
in  character  according  to  the  individual ; 
sometimes  a  slight  rubbing  and  again 
a  true  crackling,  which  resembles  that 
of  a  joint  affected  with  dry  arthritis. 
The  pressure  on  the  observer's  hand 
should  be  moderate.  In  52  epileptic 
women  this  sign  was  obtained  but  once: 
i.e.,  in  a  woman  who  had  been  com- 
mitted many  times  for  drunkenness.  M. 
B.  Damon  (Northwestern  Lancet,  July 
15,  1901). 

Treatment.  —  External  heat  should  be 
applied,  especially  to  the  abdomen  and 
feet;  the  room  should  be  heated;  the 
stomach  should  be  emptied  and  washed 
out  with  warm  or  tepid  water.  No  alco- 
hol is  to  be  given,  but  warm  milk;  if 
emesis  occur,  milk  with  soda  or  lime- 
water,  barley-water,  or  rice-water;  if 
there  is  collapse  cinnamon  (or  ammonia 
in  small  doses)  may  be  added  to  the  milk, 
or  cardamoms,  cinnamon,  and  ginger  in 
warm  water.  Chloroform,  given  with 
care,  has  been  recommended  against  con- 
vulsions. 


ALCOHOLISM.    ALCOHOLIC  INTOXICATION.     ALCOHOLIC  DELIRIUM. 


201 


In  slight  eases,  an  emetic  and  warmth. 
Ipecac  or  an  hypodermic  injection  of 
Vio  grain  of  apomorphine  may  be  used 
to  produce  emesis. 

Ammonium  carbonate  has  been  used 
with  great  success  in  doses  of  1  drachm 
dissolved  in  water.  It  acts  as  an  emetic 
and  antidepressant. 

The  patient  should  be  deprived  of  alco- 
hol, confined  in  bed,  an  i  then  given  blue 
pill,  followed  by  a  saline  cathartic.  In- 
somnia should  be  met  by  the  wet  pack. 
Strychnine  nitrate,  'A:;  to  'Ao  grain, 
should  then  be  administered  and  nutri- 
tion supported  by  water,  milk,  koumiss, 
broths,  soups,  meat-juice,  raw  eggs, 
arrowroot,  fruits,  etc.  When  required, 
bromide  and  chloral  or  duboisine  is 
ordered.  Peterson  (Jour.  Amer.  Med. 
Assoc,  Apr.  15,  '93). 

In  acute  alcoholism  apomorphine  hy- 
drochloride does  in  minutes  what  bro- 
mides and  chloral  do  in  hours.  It  is  far 
superior  to  morphine,  as  it  eliminates  the 
poison,  while  morphine  dries  up  the  se- 
cretions. Injected  hypodermically  '/,o 
grain  of  apomorphine  hydrochloride 
caused  free  emesis  in  four  minutes; 
rigidity  changed  to  relaxation,  and  ex- 
citement to  sleep.  Tompkins  (Merck's 
Archives;    Can.  Pract.,  Dec,  '99). 

In  study  of  carefully  kept  records  of 
10  hospital  cases  and  personal  expei'ience 
in  the  use  of  digitalis  in  6  cases  the  fol- 
lowing personal  conclusions  are  offered: 
1.  The  indiscriminate  use  of  large  doses 
(half  an  ounce)  of  digitalis  in  acute  alco- 
holism is  fraught  with  danger.  2.  The 
kind  of  cases  in  Avhich  it  should  be  given 
are  the  strong,  robust  patients  in  early 
life,  suffering  from  no  complications,  and 
with  violent  delirium.  In  these  cases  the 
result  will  be  exceptionally  favorable. 
They  become  quiet,  go  to  sleep  with  a 
certainty  and  promptness  that  is  not  ob- 
tained by  other  methods.  3.  If  after 
three  doses  no  narcotic  effect  is  noted  a 
continuance  is  not  advised.  In  the  above 
class  of  eases  it  can  be  used  with  perfect 
safety  for  a  limited  number  of  doses.  4. 
The  failures  in  personal  cases  were  in 
chronic  alcoholic  subjects,  in  middle  and 


advanced  life,  in  ansemio  individuals  with 
bad  nutrition.  5.  One  fact  noted  in  tlie 
cases  which  showed  marked  results  from 
the  treatment  was  that  when  they  re- 
covered and  awoke  from  their  sleep  they 
were  in  such  good  condition  that  they 
were  able  to  leave  the  hospital  at  once. 
This  is  an  unusual  experience,  as  ordi- 
narily convalescence  is  delayed  for  two 
or  three  days.  H.  P.  Looniis  (Med. 
News,  Aug.  18,  1900). 

Many  deaths  ascribed  to  acute  alco- 
holism are  really  due  to  acute  nephritis, 
but  usually  to  an  acute  exacerbation  of 
chronic  alcoholic  nephritis,  as  acute  ne- 
phritis, following  an  alcoholic  debauch, 
in  previously  normal  kidneys,  is  ex- 
tremely rare. 

If  drunkards  were  taken  to  a  hospital 
instead   of  to   a  jail,  were  put  into   a 
warm  bed,  then  catheterized,  and  an  ex- 
amination of  the  urine  made  at  once,  the 
latter  would  often  be  found  loaded  with 
albumin,  urea,  blood-casts,  uric  acid,  and 
epithelium:  a  condition  which,  if  allowed 
to  continue,  soon  results  in  ursemic  coma 
and    death.      Many    cases    treated    by 
means  of  active  purgation,  diuresis,  dia- 
phoresis,  and  active   cupping  would  be 
restored  to  normal  health.  N.  B.  Ormsby 
(Cleveland  Med.  Gaz.,  No.  4,  1901). 
Acute  Alcoholic  Delirium    (Delirium 
Tremens). — This  disorder  chiefly  occurs 
in    habitual    drinkers;     but    it    is    also 
obseryed    in    ordinary    temperate    per- 
sons  after   a   prolonged    drinldng-spell. 
Though    mostly    met    with    in    spirit- 
drinkers,  it  is  seen  occasionally  in  beer-, 
wine-,  and  cider-  drinkers. 

Symptoms.  —  There  are  two  forms, — 
the  traumatic  and  the  idiopathic.  They 
differ  little  except  in  the  prodromata. 
In  the  traumatic  form,  after  an  accident 
(sometimes  a  slight  traumatism)  the 
characteristic  tremors,  etc.,  appear  fre- 
quently without  warning;  but,  in  the 
idiopathic  form,  the  patient  who  is  about 
to  have  an  attack  is  restless,  uneasy,  irri- 
table, sleeps  badly  if  at  all,  suffers  from 
digestive  troubles,  and  has  little  desire 
for  food.    Delirium  then  appears.    The 


202 


ALCOHOLISM.    ALCOHOLIC  DELIRIUM.    ACUTE.     SYMPTOMS. 


patient  cannot  rest,  but  must  be  in  con- 
stant motion.     He  is  shalving  all  over 
("the  shakes"),  is  consumed  with  terrors, 
continually  in  deadly  fright   of  things 
which  he  mentally  sees,  or  of  persons 
whom  he  thinks  are  after  him  for  the 
commission  of  some  crime.     At  other 
times  his  dread  is  of  something  terrible, 
though  he  cannot  tell  what  it  is.    He  is 
all  the  while  trying  to  escape  from  these 
well-defined  or  undefined  horrors,  and, 
in  attempting  to  escape,  fatalities  some- 
times occur.    Hallucinations  of  sight  are 
most  common:  snakes,  rats,  mice,  loath- 
some things,  flames,  and,  in  a  case  of  the 
writer's,   roaring   lions   bounding   down 
the  chimney,  below  the  chairs,  and  rush- 
ing in  at  the  windows.    The  delirium  is 
best  described  as  one  of  busy  wakeful- 
ness and  suspicion.     There  is  a  third 
non-febrile  innocent  form,  in  which  the 
temperature  does  not  rise  above  100°  F. 
The  visual  imagery  of  acute  alcoholic 
delirium  is  also  characteristic  of  chronic 
alcoholic  alienation.     They  are  not  pri- 
mary, but  secondary  or  illusional  hallu- 
cinations.   The  uniformity  of  the  animal 
visual  imagery  arises  from  the  influence 
of  physical  conditions  on  nervous  tissue 
made  abnormally  susceptible  by  alcohol. 
Normally  there  is  objective  projection  of 
appropriate    images    in    motion,    and    it 
needs  but  a  retinal  condition  sufficient  to 
intensify    the    retinal    images    of    these 
entoptic  objects,  and  a  cortical  state  of 
higher  impressionability  permitting  them 
to  dominate  consciousness,  to  induce  a 
kind   of  ideation  in   which   the   idea   of 
objective    motion    is    paramount.      This 
condition   is  brought  about  by   alcohol. 
Chaddock     (Alienist     and     Neurologist, 
Jan.,  '92). 

Compression  of  the  eyeball  causes  per- 
ception of  Purkinje's  figures  in  healthy 
individuals,  visions  of  objects  and  per- 
sons in  four-fifths  of  patients  suffering 
from  alcoholic  delirium.  Liepmann  (Ber- 
liner klin.  Woch.,  Apr.  8,  '95). 

Confirmatory  experiments;  vision  of 
animals  noted  in   50  per  cent,   of  cases 


of  alcoholic  delirium.  Jolly  (Berliner 
kliu.  Woch.,  Apr.  8,  '95). 

Visions  of  animals  are  present  in  40 
per  cent,  of  cases  at  most.  Such  patients 
cannot  estimate  distances.  Liepmann 
(Berliner  klin.  Woch.,  Apr.  8,  '95). 

Visions  cannot  be  attributed  solely  to 
suppression  of  the  influence  of  the  light. 
Conclusion  then  reached  that  in  those 
cases  in  which  external  excitations  do 
not  provoke  the  visions  these  are  due  to 
internal  mechanical  excitations  upon  the 
retina.  The  increase  of  the  intra-ocular 
pressure  due  to  the  contraction  of  the  ex- 
trinsic and  intrinsic  muscles  of  the  eye, 
produced  when  the  eye  is  fixed  upon 
anything,  may  be  so  considered. 

The  inner  imaginations  of  delirious 
alcoholic  patients  do  not  refer  with  a 
strange  predilection  to  certain  animals 
or  to  scenes  of  anguish  or  fright.  Their 
character  rather  is  decided  by  the  nature 
of  the  peripheral  excitation  than  by  an 
anterior  tendency  given  to  the  mind.  If 
manifestations  of  anguish  and  the  ap- 
pearance of  certain  animals  predominate 
in  spontaneous  visions,  the  cause  should 
be  sought  for  outside  of  the  patient. 

The  author  looks  upon  his  method  as 
to  the  study  of  sensorial  illusions  in 
alcoholic  patients  as  superior  to  simple 
observation  or  questioning.  H.  Liep- 
mann (Archiv  f.  Psych.,  vol.  xxvii,  p. 
172,  '96). 

Hallucinations  of  hearing  are  not  so 
common,  but  exist  in  probably  10  to  20 
per  cent,  of  cases.  Delusions  (false  per- 
ceptions concerning  self)  are  found  in 
from  5  to  9  per  cent.,  mostly  delusions 
of  persecution.  Sometimes  there  is 
one  hallucination,  illusion,  or  delusion 
throughout,  sometimes  there  is  a  suc- 
cession. 

Case  of  an  army-engineer,  a  chronic 
inebriate,  in  whom  delirium  of  grandeur 
and  self-satisfaction,  with  intense  ambi- 
tions to  attain  political  prominence,  came 
on  in  a  few  hours,  after  a  long  period  of 
drinking.  Subsidence  when  spirits  were 
withdrawn  and  recurrence  on  the  re- 
sumption of  spirits.  Editorial  (Quarterly 
Jour,  of  Inebriety,  July,  '97). 


ALCOHOLISM.     ALCOHOLIC  DELIRIUil.     ACUTE.     PATHOLOGY. 


203 


The  tongue  is  white  and  furred. 
Tremor  of  this  organ,  and  especially  of 
the  muscles,  is  a  more  or  less  marked, 
"but  generall}'  present,  symptom. 

The  fever  is  not  very  high,  being 
about  100°  to  103°  F.  If  higher,  it  is 
an  unfavorable  omen.  The  pulse  is  soft, 
rapid,  and  readily  compressed.  The  skin 
is  clammy.  Insomnia  is  constantly  pres- 
ent; but  usually  sleep  and  improvement 
occur  on  the  third  or  fourth  day.  In 
unfavorable  cases  the  patient  grows 
gradually  worse  and  dies  of  heart-failure. 

Diagnosis. — Acute  alcoholism  may  be 
mistaken  for  the  delirium  of  menin- 
gitis, of  typhus  and  typhoid  fevers,  and 
•of  chronic  alcoholism.  The  history  and 
progress  of  the  case  determine  the  first 
two,  and  the  absence  or  significance  of 
thirst,  tongue  trembling,  and  tremors 
the  third. 

Pulmonary  disorders;  congestion,  es- 
pecially when  of  trarmiatic  origin;  and 
pneumonia  may  also  give  rise  to  delir- 
ium simulating  that  of  deliriiTm  tremens. 
Fractured  ribs  may  thus  become  the  pri- 
mary factor  of  violent  accesses.  The 
same  may  be  said  of  erysipelas. 

Pathology.  —  Acute  alcoholism  is  due 
to  gradually  produced  changes  in  the 
nerve-tissues,  and  especially  to  retained 
products  of  metaholism.  The  cerehral 
lesions  in  alcoholic  delirium  are  of  two 
varieties.  The  first  is  observed  in  all 
alcoholics,  and  is  due  to  the  alcohol  it- 
self: atheromatous  degeneration  of  the 
vessels,  the  degree  of  disorder  increasing 
as  the  calibre  of  the  vessel  is  reduced. 
The  nerve-cells  also  show  granular  pig- 
mentation and  fatty  degeneration. 

The  second  variety  is  derived  specially 
from  the  character  of  the  delirium,  and 
not  from  the  alcohol  itself.  It  consists 
in  congestion,  haematic  pigmentation  in 
the  capillaries  and  nerve-elements,  and 
defeneration  of  the  nerves  and  fibres  of 


the   cortex,   the   precursors   of   general 
paralysis. 

Peddie's  view,  propounded  a  quarter 
of  a  century  ago,  that  acute  alcoholism 
is  really  poisoning  from  the  accumulated 
effects  of  alcohol  on  a  nervous  and  ir- 
ritable temperament,  has  much  in  its 
favor. 

Delirium  tremens  occurs  when  a  brain, 
deteriorated  by  chronic  alcoholism,  is  in- 
fluenced by  a  toxic  agent,  either  due  to 
the  action  of  bacteria  or  to  autointoxi- 
cation from  diseases  of  the  digestive 
tract,  the  kidneys,  or  the  liver.  The 
therapeutic  treatment  is  quite  incapable 
of  abbreviating  the  duration  of  the  dis- 
ease; the  critical  sleep  caraiot  be  in- 
duced by  any  drug.  Jacobson  (Hos- 
pitalstidende,  p.  143,  '97). 

Microscopical  examination  of  the  cen- 
tral nervous  system  and  spinal  ganglia 
of  seven  cases  of  delirium  tremens.  The 
changes  were  quite  uniform,  and  con- 
sisted essentially,  first,  in  thickening  of 
the  walls  of  the  arteries,  proliferation  of 
the  connective  tissue  in  the  media,  and 
dilatation  and  infiltration  of  the  lymph- 
spaces.  These  changes  were  more  pro- 
nounced in  the  cortex,  and  frequently 
led  to  minute  hssmorrhages,  as  many 
as  two  hundred  of  these  having  been 
counted  in  a  square  centimetre  of  the 
cortex.  The  capillaries  appeared  to  be 
proliferated,  particularly  in  one  case,  but 
they  and  the  veins  showed  no  pronounced 
anatomical  alteration.  The  neuroglia- 
fibres  of  the  cortex  showed,  according  to 
"Weigert's  new  method,  considerable  pro- 
liferation. The  Weigert  cells  were  more 
numerous  than  normal.  The  fi-ee  nuclei, 
both  the  small  and  large  varieties,  were 
increased  in  number  in  the  second  and 
sixth  layer  of  the  cortex,  and  appeared 
to  be  accumulated  around  the  degener- 
ating cells.  The  spinal  cord  was  ap- 
parently normal.  There  was  no  degener- 
ation of  the  fibres  in  the  spinal  cord,  but 
the  tangential  fibres  of  the  cortex  were 
somewhat  thinned.  The  changes  in  the 
cells  were,  as  is  usual  in  such  cases,  lim- 
ited to  certain  cells,  and  not  uniform.  In 
the  spinal  ganglia,  the  cells  stained  less 
distinctly.     The  nucleus  was  contracted, 


204 


ALCOHOLISM.    ALCOHOLIC  DELIRIUM.    ACUTE.    TEEATJMENT. 


and  in  the  end  its  membrane  appeared 
to  have  become  dissolved;  the  nucleolus 
showed  a  curious  angular  deformitj'. 
The  cells  of  the  anterior  eornua  showed 
in  the  lumbar  region  central  chromatol- 
ysis  without  staining  of  the  ground- 
substance,  and  an  increase  in  size  and 
decrease  in  part  of  the  chromaphilic 
bodies,  with  alterations  in  the  nuclei.  In 
some  eases  vacuolation  of  the  cells  had 
occurred.  The  cells  of  Purkinje  showed 
slight  change  or  no  alterations.  The 
pyramidal  cells  of  the  cortex  were 
usually  degenerated,  showing  contrac- 
tion, alteration  of  the  nucleus,  and  al- 
terations in  the  ground-substance.  The 
giant  pj'ramidal  cells  of  the  paracentral 
lobule  were  nearly  all  diseased.  In  gen- 
eral, it  was  noted  that  the  parietal  and 
occiptal  regions  were  less  affected  than 
the  others.  Tromner  (Archiv  f.  Psy- 
chiatric, B.  31,  H.  3,  '99). 

Brain-cells  in  10  cases  of  acute  alco- 
holism studied,  the  brains  being  investi- 
gated by  the  Nissl  method  of  staining 
with  methyl-violet:  (a)  patients  who 
died  of  alcoholism  with  all  the  symptoms 
of  meningitis  showed  on  necropsy  simple 
congestion  of  the  membranes  (pia  arach- 
noid), with  some  oedema  in  its  texture; 
(6)  microscopical  examination  rarely 
showed  any  migration  of  leucocytes  or 
anything  approaching  encephalitis;  (f) 
the  larger  (pyramidal  and  giant)  nerve- 
cells  showed  pigmentation  to  an  intense 
degree,  the  pigment  being  diffused 
through  the  cell-body;  (d)  the  cyto- 
plasm showing  various  degrees  of  degen- 
eration (fatty  and  granular) ;  (e)  the 
cell-body  generally  was  shrunk,  and  the 
nucleus  partially  so;  (f)  pericellular 
nuclei  had  proliferated,  and  were  freely 
present  in  the  pericellular  sacs.  In  cases 
where  death  was  due  to  exhaustion  the 
shrinkage  of  cells  was  marked.  Dana 
(Quart.  Jour,  of  Inebriety,  Jan.,  '99). 

Etiology.  —  Aciite  alcoholism  may  be 
due  to  a  temporary  exacerbation  during 
continnons  alcoholic  intoxication, — the 
idiopathic  form;  or  to  an  accident, 
sudden  shock,  or  an  acute  inflammation^ 
especially  pneumonia, — the  traumatic 
form. 


Study  of  247  recovered  personal  cases 
of  delirium  tremens.  Of  these  cases  202 
were  uncomplicated  and  45  complicated 
by  other  diseases.  Although  the  delirium 
tremens  cannot  be  regarded  as  caused 
by  the  action  of  the  pneumocoeeus,  it 
resembles,  in  all  features,  an  infectiou.s 
disease:  it  has  a  stage  of  incubation, — 
a  duration  of  about  four  days ;  it  end.s 
with  a  critical  sleep;  is  accompanied  by 
rise  of  temperature  and  almost  in  all 
cases  by  albuminuria ;  and  when  autopsy 
is  made  the  spleen  is  generally  found  to 
be  the  seat  of  parenchymatous  degen- 
eration, as  well  as  the  heart,  the  kid- 
neys, and  the  liver.  Jacobson  (Hos- 
pitalstidende,  p.  143,  '97). 

Prognosis.  —  In  private  practice  the 
prognosis  is  favorable  in  ordinary  cases; 
in  hospital  practice  it  is  much  less  so. 
Of  1241  cases  admitted  to  the  Philadel- 
phia Hospital  ditring  a  fixed  period,  121 
died.  Eecurrence  occurs  if  drinking  is 
continued. 

[I  have  noted  recurrence  from  one  to 
five  times  in  104  out  of  442  cases  treated 
in  a  special  institution.  Noeman  Kerb.] 

Treatment.  —  The  patient  must  be 
kept  in  bed  and  carefully  watched. 
Strapping  in  bed  should  not  be  prac- 
ticed, as  the  restraint  causes  muscu- 
lar movements  and  delirium.  A  sheet 
tied  across  the  bed  is  preferable,  as  this 
allows  more  freedom  of  motion.  Attend- 
ants or  a  padded  room  is  best  of  all.  No 
alcohol  should  be  given,  the  strength 
being  sustained  by  foods,  milk,  soups, 
etc. 

Experience  based  on  2012  cases  of  al- 
coholism warrants  the  statement  that 
alcohol  in  any  form  or  quantity  is  in- 
jurious, and  that  its  absolute  and  im- 
mediate withdrawal  is  important.  Lati- 
mer (Boston  Med.  and  Surg.  Jour.,  .lune 
16,  '92). 

If  the  delirium  comes  on  abruptly, 
the  exciting  causes  are  acute  and  point 
to  the  formation  of  toxins.  If  the 
delirium   has   been   preceded  by   mental 


ALCOHOLISM.     ALCOHOLIC  DELIRIUM.     ACUTE.     TREATMENT. 


205 


eliaiiges,  and  transient  alterations  of 
thought  and  conduct  occur,  gradually 
becoming  constant  and  fixed,  there  are 
indications  of  organic  lesions  of  the 
brain.  It  is  important  to  ascertain 
whether  the  delirium  follows  from  a 
long  period  of  continuous  drinking  or 
whether  the  drink  was  preceded  by  some 
physical  or  mental  disturbance  arising 
from  organic  disease,  traumatism,  or 
mental  strain.  T.  D.  Crothers  (Med. 
Record.  Dee.  14,  1901). 

Potassium  bromide,  V2  drachm,  with 
tinctiu'e  of  capsicum,  given  every  three 
hours,  is  recommended  for  mild  cases 
by  Osier. 

Sleei3  should  be  procured,  and  the 
strength  supported.  As  an  hypnotic, 
chloral  may  be  given  if  the  heart  be  not 
weak. 

In  alcoholic  delirium  the  real  chance 
of  recovery  lies  in  sleep.  The  patient  is 
therefore  isolated  in  a  quiet,  dark,  and, 
if  necessary,  padded  room,  no  physical 
restraint  being  employed.  To  procure 
sleep  the  patient  is  given  1  to  1 V: 
drachms  of  chloral-hydrate,  with  V, 
grain  of  hydrochlorate  of  morphine,  in 
an  infusion  of  limes.  If  sleep  does  not 
come  on  in  about  ten  minutes,  from  Vc 
to  V3  grain  of  morphine  is  injected  hyp- 
odermically.  After  the  alcoholic  disturb- 
ance has  subsided  strychnine  or  nux 
vomica  is  given,  followed  by  hydrothera- 
peutic  measures.  If  there  should  be  gas- 
tric complication,  an  antacid,  such  as 
sodium  bicarbonate,  is  administered. 
Lancereaux  (Bull.  Gen.  de  Th(5r.,  Feb. 
15,  '93). 

In  the  young,  with  elastic  arteries 
and  sound  kidneys,  opium  can  be  given 
freely.  In  older  patients,  where  the 
vessels  are  not  in  such  good  condition, 
chloral  is  less  dangerov\s  than  opium. 
A.  Guepin  (Gaz.  Med.  de  Paris,  Feb.  10, 
'94). 

The  heroic  doses  of  these  narcotics, 
with  the  cardiac  depression  apt  to  follow 
their  exhibition,  call  for  deliberation  in 
their  administration  to  aged  and  infirm 
inebriates,  and  I  prefer,  as  an  hypnotic. 


a  simple  febrifuge  frequently  repeated, 
such  as  repeated  doses  of  liquor  am- 
monias acetatis.  Sleep,  thus  quietly  and 
safely  induced,  has  proved  much  more 
curative  than  the  sleep  for  which  the 
author  formerly  resorted  to  narcotics. 

Twenty-five  cases  of  alcoholic  delirium 
in  which  trional  was  used  with  advan- 
tage. Conclusions:  1.  Delirium  was  con- 
trolled with  greater  rapidity  and  safety 
by  trional  than  by  other  hypnotics.  2. 
In  the  majority  of  cases  a  marked 
stimulant  effect  was  observed,  possibly 
on  account  of  the  methylic  and  ethylic 
elements  which  enter  into  the  composi- 
tion of  the  drug.  3.  On  account  of  the 
low  temperature  noted  in  all  cases,  tri- 
onal must  possess  antipyretic  proper- 
ties, thereby  simulating  its  allies  of  the 
phenol  group.  4.  It  was  always  well 
borne  by  the  stomach,  and  in  one  case 
«'as  rapidly  absorbed  when  administered 
per  rectum.  5.  No  unpleasant  after- 
effects observed.  Bellamy  (N.  Y.  Med. 
Jour.,  July  21,  '94). 

Trional  of  great  value  in  insomnia. 
Morphine  or  opium  retards  the  action  of 
trional.  C.  H.  Springer  (Med.  and  Surg. 
Reporter,  Sept.  22,  '94). 

A  very  hot  bath  gradually  cooled  and 
trional,  20  grains,  in  water  containing 
10  minims  of  tincture  of  capsicum  recom- 
mended. If  in  thirt3'  minutes  there  is 
no  abatement,  10  more  grains  of  trional 
are  given.  Forced  feeding:  milk,  eggs, 
soups,  etc.  Bellamy  (N.  Y.  Med.  Jour., 
vol.  Ix,  p.  72,  '94). 

In  all  cases  of  acute  mania,  or  delirium 
tremens,  the  use  of  hyoscyamine,  or  the 
alkaloid  hyoseyine  hydrobromate,  in 
large  doses  is  recommended.  I.  A.  Mar- 
shall (Med.  Brief,  Jan.,  '98). 

A  harmless  remedy  that  will  produce 
sleep  in  a  few  minutes,  even  when  the 
patient  is  suffering  with  the  wildest  de- 
lirium, is  apomorphine.  Just  enough  is 
injected  subcutaneously  to  produce  light 
nausea,  but  not  enough  to  cause  vomit- 
ing. One-thirtieth  grain  is  the  average 
quantity  required,  but  individual  sus- 
ceptibility greatly  varies.  In  a  few  min- 
utes   after    administering    the    remedy 


206 


ALCOHOLISM.    ALCOHOLIC  DELIRIUM.    ACUTE.    TREATMENT. 


perspiration  appears  and  the  patient 
voluntarily  lies  down,  when  a  sound  and 
restful  sleep  immediately  follows.  This 
sleep  lasts  at  least  an  hour  or  two,  and, 
if  other  sedatives  are  previously  given, 
it  will  last  six  or  eight  hours.  It  is 
of  special  value  in  all  forms  of  mania, 
regardless  of  the  cause.  It  may  also  be 
given  in  full  emetic  doses  in  many  cases 
of  alcoholism  with  marked  benefit.  It 
seems  to  frequently  act  as  almost  a  spe- 
cific in  relieving  the  alcoholic  craving. 
Charles  J.  Douglass  (N.  Y.  Med.  Jour., 
Oct.  28,  '99). 

In  delirium  tremens  the  patient  should 
be  put  to  sleep  with  apomorphine,  which 
can  be  done  in  a  few  minutes  without 
danger  and  without  emesis.  He  should 
not  be  restrained  by  physical  force,  and 
allowed  alcohol  in  some  form.  He  should 
be  nourished  w  ith  milk,  eggnog,  or  some 
other  liquid  and  easily  assimilable  food. 
C.  J.  Douglass  (N.  Y.  Med.  Jour.,  Nov. 
17,  1900). 

Opium,  if  given,  should  be  adminis- 
tered cautiously,  in  the  form  of  mor- 
phine, hypodermically.  If,  after  three  or 
four  ^/4-grain  doses,  tlie  patient  is  still 
restless,  no  more  is  to  be  given. 

If  fever  is  present,  cold  douche,  bath, 
or  preferably  the  wet  pack  may  be  tried. 
If  the  pulse  becomes  too  rapid  and  weak 
cinnamon,  with  very  small  doses  of  digi- 
talis in  aromatic  spirits  of  ammonia, 
should  be  given.  Digitalis  in  large  doses 
is  dangerous.     (Osier,  Delpeuch,  Kerr.) 

Cold  baths  in  febrile  delirium  tremens 
at  18°  C,  or  tempered  according  to  in- 
dividual cases,  induce  rapid  resolution 
of  symptoms.  The  infection  and  auto- 
intoxication are  directly  antagonized. 
Well-marked  cardiovascular  disease  is  a 
contra-indication.  Salvant  (These  de 
Paris,  1901). 

The  patient  should  be  carefully  fed, 
milk  and  concentrated  broths  being 
especially  useful.  If  necessary,  nutrient 
enemata  are  to  be  administered. 

If  the  delirium  occurs  during  an  acute 


malady  or  following  an  injury,  two  in- 
dications must  be  attended  to: — 

1.  Sustain  the  patient's  strength  by 
frequent  assimilable  nourishment. 

2.  Obtain  sleep.  For  this  purpose 
opium  may  be  given  at  the  outset  in  one 
full  dose,  or  laudanum  may  be  given  by 
the  rectum. 

Chloral  may  be  given  in  doses  of  2  ^/^ 
to  3  drachms  unless  some  cardiac  or  pul- 
monary complication  or  depression  ren- 
ders its  use  dangerous. 

If  the  delirium  appears  without  ap- 
parent cause,  during  chronic  alcoholism 
or  following  recent  excesses,  the  adminis- 
tration of  alcohol  as  a  remedy  may  be- 
come necessary.  If  the  fever  be  not  too 
high,  the  delirium  too  violent,  and  if  the 
strength  of  the  patient  be  preserved,  it 
may  be  withheld;  but,  if  the  patient  be 
adynamic,  recoiirse  must  be  had  to  alco- 
hol, as  well  as  to  other  diffusible  stimu- 
lants: caffeine,  subcutaneous  injections 
of  ether,  or  draughts  of  ammonium 
acetate.  Any  form  of  narcotics  should 
be  avoided  in  these  cases.    (Delpeuch.) 

Several  cases  of  delirium  and  cerebral 
excitement  (sometimes  followed  by  loss 
of  consciousness)  witnessed  in  inebriates, 
after  a  full  dose  of  caffeine.  The  ad- 
ministration of  this  remedy  is  therefore 
contra-indicated.  In  any  event  it  should 
always  be  prescribed  with  caution,  be- 
ginning with  small  doses,  with  instruc- 
tions to  discontinue  the  medicine  on  the 
appearance  of  the  slightest  agitation. 
Czarkowsky  (Amer.  ]Medico-Surg.  Bull., 
July, '93). 

The  intravenous  infusion  of  saline  so- 
lution in  delirium  tremens  increases  the 
amount  of  the  circulating  medium  in 
which  the  toxic  materials  are  dissolved, 
thereby  diluting  the  poison  and  bathing 
the  nerve-centers  with  a  more  attenu- 
ated solution  of  the  same.  The  amount 
of  circulating  fluid  is  increased  above  the 
normal,  so  that  the  excretion  of  fluids 
through  all  the  fluid-excreting  channels 
is  increased,  thereby  carrying  off  in  so- 
lution   much    of   the    contained    toxins. 


ALCOHOLISM.     ALCOHOLIC  ilAXIA.     ACUTE.     SYMPTOiLS.     TREATMENT.    gO": 


The  action  of  the  heart  is  improved  by 
the  filling  of  the  relaxed  vessels.  These 
suffice  to  restore  the  physiological  equi- 
librium and  turn  the  balance  in  the 
favor  of  recovery.  J.  P.  Warbasse 
(Med.  News,  Mar.  2,  1901). 

Acute  Alcoholic  Mania  (Mania  a 
Potu). 

Symptoms. — The  patient,  in  wild,  un- 
governable fury,  shouts,  stamps,  strikes, 
or  kicks,  and  is,  for  the  moment,  un- 
controllable. The  eyes  roll,  the  face  is 
flushed,  and  the  veins  distended  and  en- 
gorged; the  miiscles  are  at  their  highest 
point  of  tension  and  are  in  continuous 
violent  action.  The  pulse  is  strong, 
bounding,  and  tumiiltuous.  Though 
mechanically  conscious,  the  subject  is 
filled  with  "blind  fury."  He  is  carried 
away  in  a  tempest  of  nervous  excitation 
and  passion.  The  paroxysms  of  violence 
sometimes  last  only  a  few  minutes,  at 
other  times  for  from  an  hour  to  several 
days  with  quiet  intermissions.  Earely 
are  there  delusions,  though  the  infuri- 
ated subject  may  vent  his  violence  on  the 
first  animate  or  inanimate  object  in  his 
way.  In  a  few  cases  the  fury  is  directed 
against  a  certain  person  or  thing.  Vio- 
lence is  succeeded  b}'  calm;  a  few  min- 
utes after  a  storm  the  temperature  is 
normal,  and  during  the  parox3'sm  rarely 
raised.  In  some  constitutions  a  parox- 
ysm may  be  provoked  by  a  small  quan- 
tity of  alcohol. 

Differential  Diagnosis.  —  It  may  be 
differentiated  from  delirium  tremens  by 
the  absence  of  tremors,  terror,  hallu- 
cinations, delusions,  the  white  tongue, 
nausea,  and  the  delirium  of  the  latter. 
Further,  mania  a  potu  may  arise  from  a 
small  quantity  of  an  intoxicant  taken  in 
a  short  time,  while  delirium  tremens  is 
due  to  large  quantities  taken  in  rapid 
succession,  or  from  smaller  quantities 
long  continued. 


Etiology  and  Pathology.  —  Alcoholic 
mania  is  occasionally  seen  in  chronic 
inebriates,  and  most  frequently  in  peri- 
odic tipplers.  In  the  latter  it  often 
occurs  when,  soon  after  an  interval  of 
abstinence,  an  intoxicant  is  freely  par- 
taken of.  Some  chronic  inebriates  in- 
variably suffer  acute  mania  if  they  drink 
a  single  glass  of  spirits,  wine,  or  beer 
beyond  their  usual  allowance.  The  par- 
oxysms of  acute  mania  resemble  those 
of  epilepsy,  and  a  large  proportion 
of  police-court  drunken  offenders  are 
patients  of  this  class.  The  symptoms 
are  evoked  by  the  pathological  action  of 
acute  poisoning  bj'  alcohol,  in  nervous 
systems  liable  to  such  excitation,  either 
congenitally  or  from  the  effects  of  in- 
temperance, traumatism,  or  brain-tire. 

The  forms  of  insanity  met  with  which 
result  from  alcoholism  are:  (1)  amnesic, 
(2)  delusional,  and  (3)  chronic  varieties 
which  end  in  dementia.  The  best  work- 
ing hypothesis  for  the  prevention  and 
cure  of  all  forms  of  alcoholic  disorders, 
whether  mental  or  physical,  must  be 
based  upon  the  practice  of  total  ab- 
stinence. R.  Jones  (Lancet,  Oct.  25, 
1902). 

Prognosis.  —  The  prognosis  is  mucii 
more  favorable  than  in  acute  mania,  the 
paroxysm  usually  rapidly  passing  away, 
leaving  the  patient  exhausted  and  peace- 
ful. Earely  is  there  relapse  unless  alco- 
hol be  again  taken. 

Treatment.  —  Little  treatment  is  gen- 
erally needed.  Non-alcoholic  liquids, 
such  as  milk,  iced  milk,  milk  and  soda,, 
or  saline  draughts  with  ipecacuanha  and 
small  doses  of  the  bromides  are  sufficient 
to  bring  about  recovery.  Sometimes  cold 
affusions  and,  in  prolonged  paroxysms,, 
wet  packs  prove  valiiable  adjuncts. 

When  violent  mania  is  present,  apo- 
morphine,  Vs  to  Ve  grain,  hypodermic- 
ally,  causes  nausea  and  vomiting  and 
rapid  removal  of  the  violent  symptoms. 


208 


ALCOHOLISM.    CHRONIC.     SYMPTOMS. 


Study  of  958  cases  of  alcoholism,  of 
which  40  suffered  from  acute  excitement, 
or  mania  a  potu. 

No  stimulants  given  in  any  case.    The 
uniform    prescription   was    30    gi-aing   of 
bromide  of  potassium  every  two  hours  in 
maniacal  cases,  and  every  three  or  four 
hours  in  other  cases.     In  cases  of  noisy 
mania,   ^A   grain   of   morphine    sulphate 
was  occasionally  given  hypodermically  at 
bed-time.    All  the  cases  recovered.    Lati- 
mer (Johns  Hopkins  Hosp.  Bulletin,  No. 
119,  '91). 
Chronic  Alcoholism. 
Symptoms.  —  The    intensity    of    the 
symptoms  corresponds  with  that  of  the 
functional   and   organic    disorders   pro- 
duced.     In    average    cases    the    earlier 
symptoms  are  those  indicating  nervous 
disorder,  the  most  important  being  mus- 
cular tremor.     The  hands  are  unsteady 
and  shake;  but,  in  the  majority  of  care- 
fully examined  cases,  the  lower  limbs  are 
found  to  be  afiectfid  before  the  upper 
(particularly  in  females).     The  trouble 
is  especially  marked  in  the  morning,  and 
may  be  such  as  to  render  the  use  of  the 
limbs  difficult.    At  first  an  efEort  of  the 
will  enables  the  patient  to  control  the 
movements  of  his  hands  and  feet,  but 
this  power  gradually  wanes. 

Eestlessness,  the  limbs  starting  invol- 
imtarily,  especially  after  retiring,  is  the 
first  indication  of  impending  trouble  in 
some  tipplers.  The  mind  becomes  irri- 
table; there  is  headache,  dizziness,  tin- 
nitus aurium  and  muscse  volitantes, 
while  flashes  of  light  are  frequently 
complained  of. 

Besides  the  irritability  there  is  usually 
mental  disquietude,  the  patient  being 
unable  to  settle  down  to  his  duties.  He 
frequently  labors  under  the  apprehen- 
sion that  bodily  harm  is  awaiting  him, 
whether  through  the  act  of  some  enemy, 
an  accident,  or  illness  he  cannot  tell. 
In  walking  he  experiences  at  times  the 
sensation   of  falling  down   a   precipice: 


a  bad  omen,  according  to  Anstie.  As 
the  disease  advances  the  chronic  alco- 
holic is  apt  to  become  a  prey  to  delu- 
sions of  suspicion,  while  a  prominent 
feature  is  what  may  be  designated  "nar- 
comaniaeal  imtruth,"  the  confirmed  sot 
asseverating  that  he  has  drunk  no  liquor 
even  when  seen  in  the  act. 

Delusions  as  to  locality  are  a  promi- 
nent symptom  in  chronic  alcoholic  men- 
tal derangement.  Mason  (Quarterly 
•Jour,  of  Inebriety,  July,  '92). 

Pains  around  the  limbs — especially 
at  the  wrists  and  ankles,  the  shoulders, 
along  the  muscles  of  the  spine,  and 
down  the  spine  proper — are  common. 
These  pains  are  intermittent  and  par- 
oxysmal, usually  appearing  late  in  the 
day  or  after  prolonged  exertion,  accord- 
ing to  the  fatigue  to  which  the  patient 
has  been  exposed.  These  neurotic  and 
muscular  pains  were  at  one  time  credited 
to  rheumatism. 

[Henry  Monro  narrated  the  cure  of  a 
number  of  cases  of  what  he  supposed  to 
be  alcoholic  rheumatism,  by  the  simple 
withdrawal  of  alcoholic  liquor.  The 
cases  were  most  probably  alcoholic 
multiple  neuritis  at  an  early  stage. 
NoKMAN  Keer.] 

Besides  the  disorders  of  locomotion 
attending  muscular  inco-ordination, 
there  may  be  impairment  of  sensation. 
The  lower  limbs  are  frequently  found 
wasted,  while  the  abdomen  is  found  en- 
larged and,  perhaps,  pendulous,  owing 
to  the  presence  of  adipose  tissue.  Epi- 
leptiform convulsions  are  occasionally 
observed,  while  mania,  melancholia,  and 
dementia  are  frequent  sequelse. 

Gastric  disorders  may  be  present 
early  in  the  history  of  the  case.  Nausea 
and  vomiting  are  common;  these  usually 
occur  in  the  morning,  and  have  been 
known  to  extend  to  hsematemesis  and 
death. 


ALCOHOLISM.    CHRONIC.    DIAGNOSIS.    ETIOLOGY. 


209 


Case  of  profuse  and  fatal  haimatemesis 
consequent     upon     chronic     alcoholism. 
Hancock  (Med.  Chronicle,  May,  '91). 
The  appetite  is  absent  for  the  break- 
fast in  almost  all  advanced  cases;    the 
tongue  is  coated,  and  the  breath  usually 
very  foul.    A  sensation  as  if  the  stomach 
were   sinking   is    a   frequent    symptom: 
an    important    one    in    that    it    usually 
prompts  the  patient  to  drink  to  obtain 
temporary  relief. 

The  eyes  are  congested  and  watery,  the 
features  expressionless.  The  skin  of  the 
face  is  red  and  frequently  papular:  a 
condition  known  as  "acne  rosacea"  {q.  v.). 
The  latter  disease  does  not  occur  only 
in  drunkards,  however,  functional  gastric 
and  menstrual  disorders  being  active  as 
etiological  factors  in  perfectly  temperate 
people. 

[Indeed,  the  most  aggravated  and  ob- 
stinate case  of  "acne  rosacea"  which  I 
have  ever  seen  was  a  merchant  whom 
I  have  known  to  have  been  a  strict  ab- 
stainer for  some  fifteen  years.  Norman 
Kerb.] 

The  chronic  alcoholism  of  ardent 
spirits  (whisky,  brandy,  and  gin  espe- 
cially) has  a  distinguishing  characteris- 
tic of  emaciation  with  shrunken,  though 
fiery  or  bluish,  countenance,  while  that 
of  malt  intoxicants  and  sweetish  wines 
(particularly  if  not  alcoholically  very 
strong)  exhibits  usually  a  generally 
bloated  appearance,  with  adipose  super- 
abundance. 

Differential  Diagnosis. — In  most  cases 
the  alcoholic  history,  with  the  symptoms, 
easily  discriminate  chronic  alcoholism. 
Among  the  latter,  especially  morning 
nausea,  or  sickness;  foul  ethereal  breath; 
furred  tongue,  eructations,  gastralgia  and 
gastrodynia,  anorexia,  and  cephalalgia; 
diarrhoea  or,  more  generally,  constipa- 
tion; tremors,  restlessness,  fear.  In  ad- 
vanced stages  bloated,  puffy,  or  pinched 
features;   shuffling,  ataxic  gait;   listless- 

1- 


ness,  perverted  sensations,  and  untruth. 
In  alcoholically  paralytic  cases  the  pa- 
retic symptoms  are  antedated. 

Drunkenness  should  be  discriminated 

from  inebriety.     Drunkards  drink  when 

they   have   the   opportunity;     inebriates 

are    diseased    persons    who   drink    when 

their  attack  seizes  them.     The  drunkard 

may  so  injure  his  brain,  structurally  or 

functionally,    that    he   may    become    an 

inebriate;    the  inebriate,  however,  is  one 

who  is  generally  bom  with  an  unsound 

brain.     This  is  a  transmissible  cachexia. 

The  child  of  an  inebriate,  born  after  the 

lesion  has  been  established,  inherits  some 

nervous  diathesis.     The  only  security  is 

by  life-long  abstinence  on  the  part  of  the 

child.    Stewart  (Lancet,  Jan.  9,  '92). 

Etiology.  —  Heredity    has,    by    most 

authorities,   been   considered  to  be  the 

chief  predisposing  influence.     Crothers 

traced  a  family  history  of  inebriety  in 

one-half  of  his  cases,  besides  25  per  cent. 

of  defective  brain-states  from  a  neurotic 

or  other  morbid  inheritance  inclusive  of 

insanity. 

[In  over  3000  cases  I  have  found  fully 
one-half  with  an  inebriate  ancestry,   in 
addition  to  6  per  cent,  with  a  pedigree 
of    mental    disease.      Almost    the    same 
proportions  have  been  the  experience  of 
the  American,   Fort  Hamilton,   and  the 
English  Dalrymple  Homes.    Bevan  Lewis 
attributed  64  per  cent,  to  parental  ine- 
briety,  some   form    of  transmitted   neu- 
rosis, or  insanity.     Piper,  likewise,  puts 
the  proportion  of  hereditary  to  acquired 
eases  at  two  to  one.    In  my  opinion,  the 
number  of  cases  in  which  an   ancestral 
history  of  alcoholism  has  been  traced  is 
much  below  the  actual  amount,  as  it  is 
frequently   difficult   to   get   relatives   to 
admit  the  existence  of  an  alcoholic  taint. 
Norman  Kerr.] 
Heredity  is  said  to  be  crossed  when, 
in  its  single  parental  form,  the  children 
of   the    opposite    sex   to    the   inebriate 
parent  only  are  affected.    An  important 
fact  is  that  all  these  and  other  forms 
of  alcoholic  transmission  may  be  handed 
down  by  a  parent  or  parents  who  have 
14 


210 


ALCOHOLISM.     CHRONIC.     ETIOLOGY. 


never  been  known  to  have  been  intoxi- 
cated, or  to  have  exhibited  any  uncon- 
trollable impulse  to  intoxication. 

Double  parental  alcoholism  causes  al- 
coholism; absinthism  causes  epilepsy; 
and  combination  of  absinthism  and  epi- 
lepsy a  common  cause  of  epilepsy  in 
children.  Legrain  (Brit.  Med.  Jour., 
July  20,  '95). 

The  proportion  of  hereditary  cases  has 
increased  50  per  cent,  over  the  acquired 
during  the  past  twelve  years.  Holmes 
(Med.  Pioneer,  Aug.,  95). 

Neurotic  intemperance  possesses  feat- 
ures which  serve  to  distinguish  it  from 
the  common  vice  of  occasional  and  de- 
liberate drunkenness.  Whereas  the  vice, 
once  so  prevalent  and  even  fashionable 
among  the  men  of  all  classes,  is  now  all 
but  confined  to  what  are  called  the  lower 
orders,  the  disease  is  confined  to  no  class, 
and  to  neither  sex,  and  instead  of  dimin- 
ishing seems  decidedly  on  the  increase. 
The  occasional  drunkard  seeks  com- 
panionship in  his  cups,  and  is  generally 
more  or  less  noisy  and  uproarious  in  his 
intoxication;  but  the  victim  of  this  dis- 
ease inclines  rather  to  shrink  from  obser- 
vation, and  is  generally  quiet  and  morose 
under  the  influence  of  alcohol.  J. 
Strachan  (Brit.  Med.  Jour.,  Oct.  1,  '98). 

Careful  study  of  four  hundred  alco- 
holics has  been  made  during  the  last 
fifteen  years  at  Zurich,  under  Forel's 
supervision,  and  again  the  fact  of  hered- 
ity is  emphasized.  Forty-three  per  cent, 
of  the  cases  had  one  or  both  parents 
alcoholic,  and  40  per  cent,  of  the  parents 
were  wholesale  or  retail  dealers  in 
liquors.  One  hundred  and  thirty-two, 
out  of  three  hundred  and  forty-six,  had 
become  alcoholics  without  drinking 
liquors,  consuming  merely  beer,  wine,  or 
ciders.  Alcoholism  is  most  frequent  be- 
tween 20  and  60  (93.5  per  cent.).  Below 
that  age  a  case  is  most  sure  to  be  direct 
heredity.  All  the  cases  showed  various 
physical,  mental,  and  moral  alterations; 
degeneration  of  heart,  arteriosclerosis, 
affections  of  the  stomach,  tremor,  ataxia, 
pupillary  troubles,  general  denutrition, 
etc.  One-fifth  were  sexual  per\'erts 
(hypersesthesia,  precocious  debauchery, 
inversion).    Fourteen  per  cent,  were  epi- 


leptics; in  six  cases  the  attacks  followed 
alcoholic  excess  and  disappeared  entirely 
Avhen  the  patients  refrained  from  alcohol. 
Editorial  (Quart.  Jour,  of  Inebriety, 
Jan.,   '98). 

Alcoholism  and  evil  disposition,  with 
criminal   tendencies,    are    ascribabk   to 
heredity,  according  to  Moreau.     It  has 
generally  been   found   that   the   major 
portion  of  inherited  alcoholism  is  due  to 
the  alcoholism  of  one  or  both  parents. 
[This  may  be  estimated  at  nearly  two- 
thirds,    after    an    examination    of    the 
records.     Noejian  Kerb.] 
The   transmissibility   of   an   alcoholic 
inheritance  has  been  very  generally  ad- 
mitted, among  other  writers  by  Plutarch, 
Aristotle,    Darwin,    Eush,    Morel,    Lan- 
cereaux,  Grenier,  Magnan,  Day,  Wright, 
Mason,  Carpenter,  Thompson,  Eichard- 
son,  Forel,  and  Demme. 

Alcoholic  heredity  may  be  divided  into 
single  or  double,  mediate  (parental)  or 
immediate  (grandparental,  etc.),  homo- 
geneous (transmitted  as  alcoholism)  or 
heterogeneous  (transmitted  as  some  other 
neurosis). 

An  innate  tendency  to  alcoholic  excess 
has  been  observed  in  children  of  tender 
years, — from  two  years  old  and  onward, 
by  Barlow,  More-Madden,  Langdown 
Down,  Kerr,  and  others. 

Examination  of  two  groups  of  10 
families  each  in  a  children's  hospital. 
One  group  of  57  was  affected,  more  or 
less,  by  alcohol;  the  other  of  61  was 
unaffected,  or  slightly  so.  Of  the  first 
group  20  had  inebriate  fathers,  the 
mothers  and  grandparents  being  mod- 
erate drinkers.  Only  45  per  cent,  of 
these  had  healthy  constitutions;  31  had 
inebriate  fathers  and  grandfathers,  but 
temperate  mothers  and  grandmothers; 
only  2  of  these,  or  a  little  over  6  per 
cent.,  were  healthy.  Of  the  61  children 
belonging  to  temperate  families,  82  per 
cent,  were  in  good  health.  Demme  (Brit. 
Med.  Jour.,  Sept.  27,  '90). 

Among  819  descendants  of  215  alco- 
holic families  there  Avere  121  premature 


ALCOHOLISM.     CHRONIC.     ETIOLOGY. 


211 


deaths,  generally  from  convulsions,  38 
cases  of  physical  debility,  55  of  tuber- 
culosis, and  145  of  mental  derangement. 
Among  the  remainder  were  many  cases 
of  epilepsy,  hysteria,  idiocy,  etc.  Legrain 
(Med.  Press  and  Circular,  June  13,  '94). 

When  double  parental  alcoholism  is 
of  sufficient  duration  to  induce  nerve- 
central  organic  disturbances,  a  weekly 
mind  in  the  offspring  is  inevitable.  Wil- 
kins  (K.  Y.  Med,  Jour.,  Sept.  22,  '94). 

Large  percentage  of  insane  children  in 
Germany  due  to  habitual  drinking.  Al- 
cohol produces  acquired  insanity  by  act- 
ing as  exciting  cause,  and  hereditary 
insanity  by  causing  organic  changes, 
which  are  transmitted  to  descendants. 
Habitual  drinking  is  most  detrimental  to 
offspring.  Eust  (Med.  Pioneer,  Aug., 
'95). 

The  generative  cells  of  drunkards  alco- 
holized and  their  children  are  degener- 
ates; their  resisting-force  against  alcohol 
is  thus  diminished.  Evolutionary  adap- 
tation of  mankind  to  alcohol  is  impos- 
sible. Fiirer  (Le  Bull.  Med.,  Aug.  25, 
'95). 

Experimental  dosing  of  hens'  eggs 
with  alcohol  delays  and  modifies  develop- 
ment, monstrosities  and  anomalies  result- 
ing. Frere  (Jour,  de  I'Anatomie  et  de  la 
Physiologic  Xormales  et  Pathologiques 
de  I'Homme  et  des  Animaux,  Mar.,  Apr., 
'95). 

Report  of  141  eases  of  idiocy,  epilepsy, 
dementia,  etc.,  directly  traced  to  alcoholic 
parentage  and  demonstrating  the  alco- 
holo-neuropathic  heredity  of  the  drink- 
crave,  the  drink-habit,  and  the  drink- 
vice,  and  vice  versa.  SoUier  (Alienist 
and  Neurologist,  Apr.,  '97). 

Influence  of  maternal  inebriety  on  the 
offspring.  Series  of  cases  of  chronic 
drunkard  women  who  have  borne  chil- 
dren were  selected  from  the  female  popu- 
lation of  Liverpool  prison,  among  whom 
habitual  inebriety  had  been  very  preva- 
lent. Of  120  female  inebriates  whose  his- 
tories were  ti-ustworthy  there  were  born 
600  children,  of  whom  265  (44.2  per 
cent.)  lived  over  two  years,  while  335 
children  (55.8  per  cent.)  died  when  under 
two  years  of  age,  or  were  still-born. 
With  a  view  to  establishing  comparisons 


with  a  healthy  non-alcoholic  standard, 
it  was  found  that  21  of  the  women  were 
able  to  give  details  regarding  female  rela- 
tives (sisters  or  daughters)  of  sober 
habits  who  had  contracted  marriages 
with  sober  males  and  had  borne  childi'en. 
Thus,  of  sober  mothers,  28  in  number, 
there  were  born  133  children,  of  whom  33 
(23.9  per  cent.)  died  when  under  two 
years  of  age.  Thus  the  death-rate  among 
the  children  of  the  inebriate  mothers  was 
nearly  two  and  a  half  times  as  great  as 
that  among  the  infants  of  sober  women 
of  the  same  stock. 

The  progressive  death-rate  in  the  alco- 
holic families  when  three  or  more  chil- 
dren were  born  is  shown  in  the  following 
table:— 


C.1SE5. 

Dead  and 
Stjll-bor.v. 
Per  Cent. 

80 
80 
SO 
lU 
93 

50  0 

Fourth    and  fifth-ljorn  .   .   . 
Sixth-  to  tenth-born 

65.7 
72.0 

Of  the  children  comprised  in  the  series, 
219  lived  beyond  infancy,  and  of  these, 
9,  or  4.1  per  cent.,  became  epileptic:  a 
proportion  extremely  high  as  compared 
with  the  frequency  of  epilepsy  in  the 
general  mass  of  population,  which,  ac- 
cording to  Bruce  Thompson,  is  less  than 
1  per  1000.  W.  C.  Sullivan  (Jour,  of 
Mental  Science,  July,  '99). 

Case  of  alcoholism  in  a  boy,  aged  30 
days,  whose  nurse  had  given  him  1 V* 
drachms  of  brandy  daily.  He  vomited 
regularly  after  nursing  and  slept  very 
soundly  all  night.  After  ceasing  to  give 
the  brandy,  the  infant  lost  weight  for 
two  weeks,  but  then  gained  rapidly. 
Follet  (Archives  de  Med.  des  Enfants, 
Aug.,  1902). 

Chronic  alcoholism  diminishes  the  re- 
sistance of  the  organism,  while  acute 
alcoholism  aggravates  the  infectious 
diseases  and  quickly  causes  death. 
Small  doses  of  alcohol  have  no  action 
upon  disease,  either  one  way  or  the 
other.  Yet  the  fact  remains,  that  after 
illness,  alcohol  in  moderate  amounts  is 
an  excellent  rebuilding  stimulant.  Mar- 
cel Labbe  (La  Presse  M6d.,  Aug.  16, 
1902). 


213 


ALCOHOLISM.    CHEONIC.    ETIOLOGY. 


Sex.  —  The  proportion  of  females  as 
compared  to  that  of  males  has,  until 
recent  years,  probably  been,  en  an  aver- 
age, about  one  woman  to  six  men.  But 
during  the  past  fifteen  years  or  so  there 
has  been  an  enormous  increase  of  chronic 
alcoholism  among  females,  especially  in 
England,  France,  and  the  United  States, 
though  a  considerable  increase  has  been 
observed  in  other  countries.  The  disease 
seems  to  be  more  inveterate  in  them 
than  in  males. 

Out  of  500  patients  treated  in  the  out- 
door department  of  the  Laennee  Hospital, 
in  Paris,  156  were  females  presenting 
symptoms  of  chronic  alcoholism.  Grand- 
maison  (British  Med.  Jour.,  Apr.  16,  '97). 

In  more  than  two  hundred  female  ine- 
briates, the  author  has  not  been  able  in 
any  way  to  reform  more  than  10  per 
cent,  of  them,  the  results  being  less  fav- 
orable than  in  the  ease  of  male  drunk- 
ards. I.  N.  Quimby  (Boston  Med.  and 
Surg.  Jour.,  Oct.  28,  '97). 

Age.  —  As  a  rule,  aboiit  one-half  the 
whole  number  have  occurred  between 
40  and  50,  though  there  has  been  an 
increase  in  adolescent  life,  from  18  to 
25,  these  younger  chronic  alcoholists 
specially  developing  an  homicidal  mani- 
acal tendency  (as  noted  by  Magnan,  in 
Paris).  Even  boys  of  7  years  and  up- 
ward having  been  treated  for  delir- 
ium tremens  and  chronic  alcoholism  in 
England,  and  children  are  sometimes 
sent  drunk  to  school  in  Austria. 

The  use  of  alcohol  by  children  is  one 
cause  of  the  depopulation  of  France. 
The  conclusion  reached  is  that  it  is  as 
dangerous  as  is  an  excess  of  alcoholic 
beverages  for  an  adult;  for  the  adoles- 
cent they  are  deadly,  because  they  cause 
organic  changes,  hinder  physical  develop- 
ment, and  impair  the  normal  faculties 
even  to  the  extent  of  degeneracy.  For 
these  reasons,  then,  alcohol  should  be 
proscribed  as  drink  for  children.  Lan- 
cereaux  (Jour,  des  Praticiens,  No.  42,  p. 
665,  '96,  second  series). 


[I  have  known  cases  originating  over 
70  and  even  over  80.     There  is  an  ine- 
briate climacteric,  beyond  which  period 
nervous  periodicity,  energy,  and  function 
fail  in  response   to  alcoholic  excitation, 
placed  by  Parrish  at  between  40  and  50, 
and  by  Kerr  15  years  later  in  life,  be- 
tween 55  and  65.    Norman  Keer.] 
Beligion.  —  Brahmanism,    Buddhism, 
and  Mohammedanism  predispose  against 
alcoholism  more  than  other  religions. 

Race. — Eastern  peoples,  generally,  are 
more  susceptible  than  Western  to  alco- 
holism. The  latter  (also  some  savage 
races),  with  their  intenser  energy,  take  to 
alcohol  more  impulsively  and  die  sooner 
from  it.  The  Jewish  community  pos- 
sesses a  striking  racial  inhibition  which 
has  largely  contributed  to  their  marked 
general  freedom  from  alcoholism. 

Atmospheric  qnd  telluric  conditions 
predispose  a  substantial  number  of  per- 
sons to  alcoholism.  The  form  of  the 
alcoholism  is  to  some  extent  modified  by 
atmosphere  and  climate. 

Education. — In  civilized  communities 
cultitre  and  refinement  endow  many  in- 
dividuals with  a  more  delicate  suscepti- 
bility to  alcoholic  poisoning. 

Occupation.  ■ —  Occupations  with  a  de- 
pressant or  exciting  influence  on  the 
nervous  system  predispose  to  alcoholism. 
Marital  Relations.  —  Between  single 
and  married  males  there  is  little  differ- 
ence, but,  in  women,  the  proportion  of 
spinsters  is  only  one  to  from  four  to  six 
married,  widowed,  or  divorced  women. 

Temperament. — The  nervous  and  san- 
guine temperaments  are,  by  far,  the  most 
susceptible  to  alcoholic  toxication;  the 
phlegmatic  rarely  yielding. 

Associated  Habits. — Though  the  bulk 
of  the  subjects  of  alcoholism  are  smok- 
ers or  users  of  tobacco  in  some  form, 
the  popular  idea  that  tobacco-use  largely 
predisposes  to  alcoholism  seems  to  be 
without  foundation. 


ALCOHOLISM.  CHRONIC.  PATHOLOGY. 


213 


[I  have  seen  only  a  very  few  such 
instances.  Only  to  a  limited  extent  does 
any  othei-  narcotic,  such  as  morphine  or 
cocaine,  act  as  a  predisposing  influence. 
Norman  Keek.] 

Diseases  and  Injuries.  —  In  no  incon- 
siderable ntimber  of  cases  syphilis  pre- 
disposes to  chronic  alcoholism.  Phthisis, 
gout,  rheumatism,  malarial  poisoning, 
the  neuroses,  diabetes,  and  other  ail- 
ments exert  a  similar  influence.  In- 
juries and  sun-strokes,  head-lesions,  and 
heat-apoplexy  often  leave  mental  im- 
pairment and  inability,  which  induce  sus- 
ceptibility to  take  on  alcoholic  narcotic 
disturbance  and  addiction. 

An    intelligent   and    educated    woman 
never    becomes    a    drunkard    but    from 
some    deep-rooted    and    often    carefully- 
concealed  cause,  which  may  be  physical 
or    mental.      Lawson    Tait    (Brit.    Med. 
Jour.,  Oct.  15,  '92). 
Diet. — Improper,  defectiye,  and  badly- 
cooked  food,  with  bad  hygienic  condi- 
tions, frequently  act  as  predisposing  fac- 
tors.   A  considerable  degree  of  alcoholic 
predisposition,  in  the  person  of  the  regu- 
lar, limited  drinker  and  his  progeny,  is 
the    direct    effect    of    chronic    alcoholic 
poisoning.    The  gradual  alcoholic  paral- 
ysis   of   inhibition   induces   a    lessened 
capacity  to  resist  the  narcotizing  action 
of  the  alcohol. 

Most  of  these  influences  operate  also 
as  causes  exciting  to  intoxication.  In 
addition,  there  are  nerve-shock  in  both 
sexes,  the  functional  crises  of  puberty, 
menstruation,  pregnancy,  maternity, 
lactation,  and  the  menopause  of  women, 
monotonous  dullness,  and  medical  pre- 
scribing. Nerve-shock  of  some  kind 
probably  accounts  for  from  a  seventh 
to  a  sixth  of  chronic  alcoholics. 

[In  my  experience  about  2  per  cent, 
of  cases  have  arisen  from  head  injuries 
immediately  after  the  excitation  conse- 
quent thereon;  and  V2  of  1  per  cent, 
from     alcoholic     intoxicants     medically 


prescribed.  Alcoholic  drinks  and  pro- 
prietary preparations  containing  alcohol 
are  also  taken  or  given  as  a  "remedy"  or 
"medicine"  under  non-medical  advice,  by 
nurses  and  other  unqualified  persons. 
XOKIIAN  Kekr.] 

A  common  assertion  is  that  doctors' 
prescriptions  are  one  of  the  chief  causes 
of  drunkenness.  In  a  study  of  the  sub- 
ject in  over  3000  eases  of  inebriety  I  was 
unable  to  trace  the  initiation  of  the  alco- 
holism as  due  to  medical  prescription  in 
more  than  ^/„  per  cent. 

Pathology. — Protoplasm. — The  experi- 
ments of  Dogiel,  B.  W.  Eichardson,  and 
others  indicate  that  alcohol,  even  in  very 
small  quantities,  affects  protoplasm,  and 
therefore  the  entire  system.  It  tends  to 
cause  cessation  of  the  amoeboid  move- 
ments of  the  white  blood-corpuscles,  and, 
through  this,  increases  the  liability  to 
suppuration  and  the  sluggish  reparative 
action  observed  in  drunkards.  Its  gen- 
eral effect  is  to  inhibit  vital  phenomena 
inherent  in  the  protoplasm,  hindering 
thereby  the  resistance  of  the  body  to 
infectious  diseases,  while  the  multiplica- 
tion of  various  bacilli  in  the  presence  of 
even  minute  quantities  of  alcohol  would 
seem  to  indicate  that  the  life  and  growth 
of  destructive  elements  are  promoted. 
The  blood  is  improperly  aerated  and 
waste  material  is  unduly  retained  in  the 
body. 

The  ■walls  of  cells  inclosing  germinal 
matter  are  dissolved,  free  albumin  is 
coagulated,  red  globules  are  deprived  of 
part  of  contents,  leaving  them  shrunken; 
growth  of  tumors  favored,  metabolic 
action  limited,  organization  of  neuro- 
dynia of  gray  matter  reduced  or  pre- 
vented. Wilkins  (N.  Y.  Med.  Jour., 
Sept.  22,  '94). 

Alcohol  lessens  the  absorption  of  oxy- 
gen by  the  blood-corpuscles  and  the 
exhalation  of  carbonic  dioxide.  Every 
function  of  the  body  is  thereby  affected. 
Prout,  Edward  Smith,  Harley,  Schmiede- 


214 


ALCOHOLISM.    CHRONIC.    PATHOLOGY. 


berg,  Yierordt,  Kerr,  and  others  (Med. 
Pioneer,  Oct.,  '95). 

The  continual  ingestion  of  alcohol 
causes  atrophy  of  elementary  organisms, 
tending  to  destroy  cellular  protoplasm 
and  vitality.  Gaule  (Le  Bull.  Med.,  Aug. 
25,  '95). 

Even  in  minute  quantities  alcohol 
favors  the  growth  of  many  pathogenic 
organisms,  including  those  of  pus  and 
diphtheria.  Ridge  (Med.  Pioneer,  Oct., 
'95). 

Alcoholized  animals  not  only  show  the 
effects  of  inoculations  earlier  than  do 
non-alcoholized  rabbits,  but,  in  the  case 
of  the  streptococcic  inoculations,  the 
lesions  produced  are  much  more  pro- 
nounced than  are  those  that  usually 
follow  inoculation  with  this  organism. 
A.  C.  Abbott  (Jour,  of  Exper.  Med.,  vol. 
i.  No.  3,  '96). 

Cases  showing  marked  inhibitory  in- 
fluence of  alcoholism  on  the  growth  of 
children.  Lancereaux  (La  Presse  Med., 
Oct.  14, '96). 

Stomach. — The  interior  of  the  stomach 
presents  a  dark  bluish-red  hue,  some- 
times looking  very  fiery  and  angry;  while 
ulcerative  erosive  patches,  thinning  of 
muscular  coat,  with  an  increase  of  con- 
nective tissue  and  atrophy  of  gland-cells, 
are  also  conditions  usually  observed.  In 
malt-liquor  chronic  alcoholists  there  is 
dilatation.  The  irritation  of  the  gastric 
mucous  membrane  hinders  digestion,  and 
thereby  interferes  with  the  nutrition  of 
the  patient. 

Autopsy  of  nineteen  inebriates.  Five 
showed  inflammation  of  the  stomach 
alone.  In  two  of  these  the  mucous 
membrane  of  the  stomach  was  black  and 
thickened,  and  in  places  ulceration  had 
taken  place.  Of  the  other  seven,  three 
had  suffered  from  both  gastritis  and  en- 
teritis, while  the  remaining  four  had 
suffered  from  extensive  inflammation  of 
some  part  of  the  intestinal  canal,  a 
majority  of  them  suffering  fi'om  colitis. 
A  remarkable  feature  in  these  twelve 
gastro-intestinal  cases  was  that  every- 
one had,  at  some  period  of  their  lives, 
suffered    from    pleurisy    or    pleuro-pneu- 


monia,  for  pleural  adhesion  existed  in 
every  case.  Carpenter  (Western  Med. 
and  Surg.  Reporter,  Jan.,  '91). 

Digestion. — The  irritation  of  the  gas- 
tric mucous  membrane  hinders  digestion. 
Alcohol  impairs  all  the  gastric  functions, 
and  thus  interferes  with  the  general 
nutrition. 

Experiments  on  five  young  men:  Al- 
cohol used  in  a  25-  and  50-per-cent.  solu- 
tion, of  which  3  y,  fluidounces  were  taken 
ten  or  twenty  minutes  before  the  pa- 
tient's dinner  (consisting  of  soup,  cutlet, 
and  bread).  Conclusions:  1.  During  the 
first  three  hours  after  the  ingestion,  the 
gastric  digestion  is  markedly  retarded, 
and  dependent  upon  a  decrease  in  the 
proportion  of  hydrochloric  acid.  2.  The 
diminution  is  especially  pronounced  in 
persons  non-habituated  to  the  use  of  al- 
cohol. 3.  Stronger  solutions  of  alcohol 
act  more  energetically  than  weaker  ones. 
4.  During  the  fourth,  fifth,  and  sixth 
hour  after  the  meal  the  digestion  be- 
comes considerably  more  active,  the  pro- 
portion of  hydrochloric  acid  markedly 
rising.  5.  Under  the  influence  of  alcohol, 
the  secretion  of  the  gastric  juice  becomes 
more  profuse  and  lasts  longer  than  under 
normal  conditions.  6.  The  motor  and 
absorptive  powers  of  the  stomach,  how- 
ever, are  markedly  depressed,  the  de- 
crease being  directly  proportionate  to  the 
strength  of  alcoholic  solutions  ingested. 
7.  Alcohol  distinctly  retards  the  passage 
of  food  from  the  stomach  into  the  duo- 
denum. 8.  On  the  whole,  alcohol  mani- 
fests a  decidedly  unfavorable  influence 
on  the  course  of  normal  gastric  digestion. 
Even  when  ingested  in  relatively  small 
quantities,  the  substance  tends  to  impair 
all  gastric  functions.  9.  Hence,  an  habit- 
ual use  of  alcohol  by  healthy  people  can- 
not possibly  be  approved  of  from  a  physi- 
ological stand-point.  Blumenau  (Inaugu- 
ral Dissertation,  No.  17,  p.  60,  '90) . 

Ptyalin  of  saliva  and  pepsin  precipi- 
tated; gastric  vasodilators  paralyzed, 
while  the  constrictors  are  stimulated, 
preventing  flow  of  gastric  juice  and  ac- 
counting for  irritability,  anorexia,  etc. 
Stomach  inflamed  and  covered  with  thick 
mucus.     Duodenal  and  panci'eatie  func- 


ALCOHOLISM.  CHRONIC.  PATHOLOGY. 


215 


tion  prevented.  Stearin  dissolved  out  of 
the  fat  by  alcohol,  remaining  elements 
contributing  to  fatty  degeneration  of 
various  organs.  Excessive  use  continued 
any  length  of  time  prevents  rehydration 
of  glycogen  and  its  transfer  to  the  blood, 
and  oxygenation  of  bilirubin  to  form 
biliverdin.  In  this  sense,  even  a  small 
quantity  of  alcohol  is  inimical  to  life. 
Wilkins  (N.  Y.  Med.  Jour.,  Sept.  22,  '94). 

[Sir  William  Roberts's  view,  that  we 
are,  as  a  rule,  suffering  not  from  slow, 
but  from  too  rapid,  digestion,  and  that 
we  therefore  need  alcohol,  not  to  aid 
digestion,  but  to  hinder  it,  can  hardly 
be  accepted.  Clinical  observations  of 
performance  of  digestive  function  in  liv- 
ing human  subjects  does  not  exhibit,  as 
a  rule,  improved  digestion  after  the  ad- 
ministration of  alcohol.  NOKiiAN  Kerb, 
Assoc.  Ed.,  Annual,  '96.] 

It  would  appear,  from  a  study  of  many 
cases,  that,  so  far,  no  general  rule  can  be 
found,  and  each  case  must  be  studied 
from  the  facts  of  its  history.  Thus,  in 
some  cases,  a  meat  diet  is  literally  poi- 
sonous, and  its  removal  is  the  first  essen- 
tial for  a  cure.  Again,  a  grain  or  fruit 
diet  is  clearly  injurious,  and  more  rapid 
recovery  follows  a  change.  In  all  cases 
states  of  starvation  and  autointoxica- 
tions exist  the  removal  of  which  condi- 
tions may  be  of  equal  importance  to  that 
of  alcohol.  The  study  of  the  diet  brings 
out  many  unsuspected  causes  which  re- 
quire removal  and  treatment  before  a 
cure  can  be  effected.  Editorial  (Quar- 
terly Journal  of  Inebriety,  Oct.,  '97). 

Liver.  —  The  liver  is  frequently  af- 
fected by  one  of  the  various  forms  of 
cirrhosis.  The  proclivity  of  each  indi- 
vidual bears  considerable  influence  upon 
the  development  of  this  disease,  however. 
The  other  hepatic  chronic  disorders  most 
apt  to  be  encountered  are  fatty  and  nut- 
meg liver.  Acute  hepatitis  is  less  fre- 
quently met  with. 

The  lesions  found  in  the  acute  form 
of  alcoholic  hepatitis  are  like  those  ob- 
ser\-ed  in  infectious,  suppurative  hepa- 
titis, showing  the  identity  of  effects 
between  infectious  and  toxic  processes. 
Pilliet  (La  Tribune  Med.,  Apr.,  '90). 


The  ascites  of  cirrhosis  is  habitually 
absent  in  connection  with  the  cirrhotic 
alterations  of  the  liver  in  the  alcoholic 
insane.  Klippel  (Annales  M6dico-psy- 
chologiques,  Sept.,  Oct.,  '94). 

Case  of  acute  alcoholism  in  which  the 
hepatic  functions  were  suppressed  during 
twenty-one  days.  Cassaet  (Le  Bull. 
Med.,  Oct.  31,  '94). 

Experimental  alcoholism  in  animals 
causes  preliminary  gastric  catarrh,  then 
fatty  degeneration  of  the  liver.  Koulbine 
(La  Med.  Mod.,  Jan.  16,  '95). 

Histological  examination,  in  two  rab- 
bits which  were  subjected  to  progress- 
ively increasing  doses  of  wine.  There 
were  traces  of  an  irritating  influence 
upon  the  liver,  which  were  found  princi- 
pally in  the  central  parts  of  the  lobes. 
The  connective  tissues  of  the  portal 
spaces  did  not  present  lesions  that  were 
very  clear,  but  the  subhepatic  veins  and 
the  capillaries  were  filled  with  leucocytes 
and  proliferated  endothelial  cells.  The 
glandular  parenchyma  was  remarkable 
for  the  considerable  size  of  its  nuclei, 
which  were  vesicular;  the  cellular  proto- 
plasm seemed  to  be  intact.  One  had 
died  at  the  end  of  twenty  days,  without 
presenting  any  visceral  alterations.  The 
other  had  died  after  thirty  days,  and 
presented  haemorrhage  of  the  stomach. 
The  liver  was  of  a  pale-grayish  color  and 
tlie  spleen  was  tumefied.  Lancereaux 
(La  Presse  Med.,  Oct.  14,  '96). 

With  the  above  conditions  is  often 
associated  a  special  facies,  consisting  in 
watery,  blood-shot  eyes,  sometimes  yel- 
lowish from  bile,  and  in  enlarged  venules 
on  the  nose  and  cheeks;  at  times,  acne 
rosacea. 

At  an  early  stage  the  eyes  of  chronic 
drunkards  present  the  following  symp- 
toms: Catarrhal  conjunctivitis,  conges- 
tion of  the  iris,  spasm  of  accommodation, 
contracted  pupils,  photophobia,  nycta- 
lopia, a  glimmering  sensation  in  bright 
light,  scotomata,  amblyopia,  and  partial 
atrophy  of  the  optic  nerve.    (May.) 

Pancreas  and  Intestines.  —  The  inter- 
ference   presented    by    alcohol    to    the 


216 


ALCOHOLISM.  CHRONIC.  PATHOLOGY. 


proper  digestion  of  fats  is  mainly  respon- 
sible for  the  fatty  degeneration  of  the 
heart  and  other  organs  generally  en- 
countered at  autopsies.  The  pancreatic 
secretion  being  coagiilated  by  the  alco- 
hol, the  fat  is  not  emulsified. 

Although  the  coagulated  secretion  is 
redissolved  into  its  former  elements  by 
pure  water,  it  is  impossible  to  restore  it 
in  the  presence  of  alcohol,  as  there  is  a 
mixture  of  water  and  alcohol  in  which 
the  secretion  will  not  dissolve.  The 
stearin  of  the  fat  is  dissolved  by  the 
alcohol  out  of  the  fat-globules.  This 
dissolution  is  probably  aided  by  the 
duodenal  secretions.  The  remainder  of 
the  fat  becomes  a  foreign  body  in  the 
circulation  and,  being  a  compound  of 
palmitin  and  olein  only,  does  not  possess 
the  property  by  virtue  of  which  it  is 
attracted  to  the  adipose  vesicle,  but  is 
deposited  in  the  different  tissues,  cavi- 
ties, and  organs,  thus  constituting  fatty 
degeneration.  Wilkins  (New  York  Med. 
Jour.,   Sept.   22,   '94). 

The  intestinal  tract  bears  the  brunt 
of  the  irritating  action  of  improperly 
digested  food,  and  gastro-intestinal 
trouble  is  frequent,  especially  in  chil- 
dren. 

Many  infants  suffering  from  acute  or 
subacute  gastro-intestinal  disease  are 
the  victims  of  unrestrained  administra- 
tion of  whisky  or  brandy,  no  definite 
direction  having  been  given  as  to  dose. 
Henry  Koplik  (Med.  Pioneer,  Feb.,  '94). 
The  ingestion  of  alcohol  causes  migra- 
tion of  microbes  from  the  intestines  to 
the  peritoneum  and  to  the  blood  of  the 
vena  porta.  Wurtz  and  Hudelo  (Le 
Bull.  M6d.,  Jan.  30,  '9.5). 

Kidneys.  —  The  structural  definition 
of  the  kidneys  is  frequently  lost  in  ad- 
vanced cases.  Their  functions  are  inter- 
fered with,  and  cumulation  of  products 
of  metabolism  is  imposed  upon  the  sys- 
tem. The  various  forms  of  nephritis  are 
natural  consequences  of  the  irritation 
produced. 

Lh-ic-acid  and  calciuni-oxalate  crystals 
are  found  in  the  urine  of  persons  in  good 


health  after  taking  alcoholic  drink,  be- 
sides an  increased  number  of  leucocytes 
with  cylinders  and  cylindroids.  It  may, 
therefore,  be  concluded  that,  even  in 
moderate  quantities,  alcohol  irritates 
the  kidneys,  the  augmented  leucocytes, 
cylinders,  and  crystals  being  due  either 
to  the  increased  metabolism  of  the  tis- 
sues or  an  alteration  by  alcohol  of  the 
relations  of  solubility  of  the  urine  salts. 
After  a  single  indulgence  this  action 
lasts  for  thirty-six  hours.  But  contin- 
uation is  cumulative.  Glaser  (Quarterly 
Jour,  of  Inebriety,  Apr.,  '92). 

First  and  most  frequent  effect  on  kid- 
neys is  polyuria,  then  diabetes  insipidus, 
followed  by  diabetes  mellitus  in  predis- 
posed alcoholics.  Wilkins  (N.  Y.  Med. 
Jour.,  Sept.  22,  '94). 

There  is  a  true  diabetes,  in  which  an 
affection  of  the  liver  is  found  preceding 
by  a  long  period  the  diabetes,  and  to 
which  the  diabetes  is  due.  These  pa- 
tients have  been  considered  until  now  as 
suffering  merely  from  diabetes,  and  not 
from  the  liver,  since  an  examination  of 
the  liver  was  necessary  in  order  to  recog- 
nize them  as  suffering  from  that  organ. 
The  alternate  phases  of  amelioration  or 
the  contrary  in  the  diabetes  coincides 
with  the  development  of  the  process  in 
the  liver;  it  may  be  recognized  by  the 
changes  in  the  volume,  form,  density, 
and  sensibility  of  the  liver. 

Of  six  cases  seen  by  the  author,  there 
were  three  in  which  diabetes  with  hyper- 
trophic liver  had  existed  for  years  who 
suddenly  developed  a  cirrhosis,  while  the 
polyuria,  glycosuria,  and  thirst  van- 
ished, to  be  replaced  by  atrophy  and 
cirrhosis  of  the  liver.  Glenard  (Mer- 
credi  Med.,  No.  44,  '94). 

Heart.  —  The  heart-failure  of  chronic 
inebriates  has  for  the  past  quarter  of  a 
century  been  continually  presenting  it- 
self in  my  experience,  often  preceded  by, 
or  contemporaneous  with,  dilatation  of 
the  muscle.  Alcohol  has  a  direct  action 
on  the  involuntary  muscular  system,  and 
the  heart  is  more  responsive  to  its  dilat- 
ing action  than  any  other  part  of  the 
bodilv  structure. 


ALCOHOLISM.     CHRONIC.     PATHOLOGY. 


217 


The  three  cardinal  symptoms  of  heart- 
failure  are  generally  observed  early  in 
alcoholic  cases,  though  the  prognosis  is 
good  providing  alcohol  he  abandoned  as 
soon  as  the  immediate  therapeutic  neces- 
sity for  its  use  has  ceased.  Graham 
Steele  (Med.  Chronicle,  Apr.,  '93). 

Dynamometer  shows  that  the  muscular 

strength  is  diminished  under  influence  of 

even  moderate  doses  of  alcoholic  drinks. 

Furer  (Le  Bull.  M6d.,  Aug.  25,  '95). 

The  heart  is  fatty  and  covered  in  parts 

by  fatty  tissue.    It  is  usually  flabby,  pale, 

and  antemortem  clots  are  likely  to  be 

formed  in  the  cavities.    These  conditions 

predispose  to  sudden  death. 

Alcoholic  myocarditis,  with  consecutive 
hepatic    disturbance    and   temporary   al- 
buminuria, is  found  as  a  clinical  form  in 
men  of  middle  age,  between  25  and  50 
years;    in  women  it  is  much  more  un- 
common.   In  all  cases  abuse  of  alcoholic 
drinks  may  be  looked  upon  as  the  cause. 
It  begins  slowly  and  progressively.     The 
first  symptom  consists  in  dyspneea,  when 
the  patient  speaks  or  goes  upstairs,  later 
during   walking.     Fragmentary  myocar- 
ditis i5  found  anatomically.    An  increase 
in  the  size  of  the  liver  is  added  to  the 
dilatation  of  the  heart.     The  kidney  is 
finally     afi^ected.       Aufrecht     (Deutsche 
Archiv  f.  klin.  Med.,  vol.  liv,  p.  615,  '95). 
Blood-vessels. — There  is  general  arte- 
rial dilation  with  atheromatous  thicken- 
ing and  brittleness,  due  to  a  cribriform 
condition  resulting  from  the  aneurismal 
dilatation.    The  motor  cells  are  enlarged 
and  pigmented,  and  their  processes  are 
covered  with  nuclei. 

Case  of  oesophageal  varicose  veins  in  a 
chronic  alcoholic  subject  who  died  from 
frequent  and  severe  hsematemesis.  The 
varices  ascribed  to  the  direct  effect  of 
alcohol  on  the  intima.  of  the  veins.  Le- 
tulle   (La  Semaine  Med.,  Oct.  22,  '90). 

It  paralyzes  the  vasoconstrictors  and, 
at  times,  vasodilators  of  capillaries, 
causing  local  hypertemia  and  stasis. 
Hypertrophy  results  from  vasoconstrictor 
paralysis,  and  atrophy  from  vasodilator 
paralysis.  Wilkins  (N.  Y.  Med.  Jour., 
Sept,  22,  '94). 


Lungs. — Chronic  alcoholism,  by  lower- 
ing the  condition  of  the  system,  renders 
more  liable  to  both  acute  and  chronic 
tuberculosis.  Pleviral  adhesions  and 
other  evidences  of  active  processes  are 
frequently  seen. 

Post-mortem  examinations  of  phthis- 
ical eases  at  St.  Thomas's,  London, 
showed  that  in  75  cases  there  was  a 
strong  history  of  alcoholism.  In  only  10 
of  these  was  there  any  history  of  in- 
herited phthisis;  in  46  (or  over  60  per 
cent.)  the  liver  was  cirrhotic.  Mackenzie 
(Brit.  Med.  Jour.,  Feb.  27,  '92). 

One  of  the  most  eflSeient  prophylactic 
measures  against  tuberculosis  would  be 
the  repression  of  alcoholism.  Thorain 
(Revue  des  Sciences  Med.  en  Fi'ance  et  3. 
I'Etranger,  July  15,  '94). 

Alcoholic    excesses    one    of    the    main 
causes    of    tuberculosis    by    predisposing 
the    system    to    bacillary    action.      The 
phthisis  of  drunkards  presents  peculiar 
characteristics  in  localization  and  evolu- 
tion:   the  lesion,  instead  of  being  in  left 
apex  in  front,  is  located  at  the  right  apex 
toward  the  back.     Improvement  usually 
follows   the    first    attack,    and    recovery 
frequently  ensues  if  the  alcoholic  habit 
is   corrected.     If  continued,   the   disease 
suddenly    assumes    alarming    character, 
involvement  of  both  lungs,  peritoneum, 
and    meninges    quickly    causing    death. 
Lancereaux  (Le  Bull.  Med.,  Mar.  6,  '95). 
The  increase  of  tuberculosis  is  propor- 
tionate to  that  of  alcoholism  in  France. 
Lagneau  (Le  Bull.  Med.,  June  26,  '95). 
Brain    and   Nervous    System.  —  The 
meninges  are  often  adherent  and  show 
inflammatory  white  patches  and  thicken- 
ing.    The  brain  is  shrunken,  with  flat- 
tened, narrow  convolutions  and  serous, 
ventricular,  and   subarachnoid   effusion. 
There  is  general  wasting  of  nerve-  cells 
and  fibres,  with  atrophied,  tangled  nerve- 
centres  and  great  increase  of  connective 
tissue.   In  the  brain-substance  congestive 
bleeding-points  are  sometimes  observed 
on  section.    Scavenger  calls  are  met  with 
in  profusion,  preying  on  nerve-elements. 
(Bevan  Lewis.) 


218 


ALCOHOLISM.    CHKONIC.    PATHOLOGY. 


Mental  disorders  and  crime  are  shown, 
by  statistics,  to  have,  in  alcohol,  one  of 
their  most  potent  etiological  factors. 

It  is  perfectly  certain  that  from  one- 
fourth  to  one- third  of  the  lunacy  of  the 
United  Kingdom  is  a  result  of  the  cus- 
tom of  drinking  alcoholic  liquors.  J.  J. 
Ridge  ("Alcohol  and  Public  Health,"  p. 
63,  '92). 

Women  charged  in  American  police- 
courts  with  drunkenness  and  associated 
offenses  are  profoundly  degenerate  in 
body  as  well  as  in  mind.  T.  D.  Crothers 
(Brit.  Med.  Jour.,  Dee.  31,  '92). 

In  fifteen  years  lunacy  has,  in  Paris, 
increased  30  per  cent.,  due  to  the  ad- 
vance of  general  paralysis  and  alcoholic 
insanity.  The  latter  is  now  twice  as 
prevalent  as  fifteen  years  ago.  Alcohol 
is  responsible  for  a  third  of  the  lunacy 
cases  at  the  Depot  Infirmary,  the  tend- 
ency being  more  and  more  to  homicidal 
mania  in  youths  of  barely  twenty.  Gar- 
nier  (Quarterly  Jour,  of  Inebriety,  Apr., 
'92). 

Histological  examinations  have  shown 
that  alcohol  causes  swelling  of  the  den- 
drites; this  is  followed  by  nuclear 
changes,  then  by  degeneration  of  the 
cell-structures. 

Examination  of  an  alcoholic  brain  by 
the  Golgi  method.  Lesions  of  the  neu- 
raxon  of  the  nerve- cell  slightly  involv- 
ing the  cell-body  and  dendrites.  Colella 
(Arch.  ItaL  de  Biol.,  p.  216,  '94). 

Alcohol  produces  well-marked  changes 
in  the  nerve-cells,  especially  in  those  of 
the  anterior  horns  of  the  spinal  cord  and 
in  the  sympathetic  ganglia.  They  first 
lose  their  cliromatin  structure,  the  fine 
granular  appearance  gradually  being 
replaced  by  an  homogeneous  swelling. 
Golgi  method.  Vas  (Archiv  fiir  exper. 
Path.  u.  Pharm..  B.  34,  p.  141). 

There  is  gradual  disintegration  of  the 
cell-body  after  the  apical  processes  have 
suffered.  Here  and  there,  in  the  neigh- 
borhood of  the  cell-body,  the  protoplasm 
seems  to  become  frayed  or  eroded.  In 
other  cases  the  cell-protoplasm  becomes 
vacuolated  from  within  until  the  entire 
protoplasmic  structure  is  channeled  by 
holes  and  seams  of  liquefaction.  Golgi 
method.     Andriezen   (Brain,  '94). 


Forty  per  cent,  of  crime  and  bad  con- 
duct come  from  inebriate  parental  de- 
generation. Corre  (Quarterly  Jour,  of 
Inebriety,  Jan.,  '94) . 

The  form  of  alcoholism  is  determined 
by  pre-existing  anomaly  of  subject;  al- 
coholic psychopathia  often  the  conse- 
quence of  parental  addiction;  psycho- 
pathia and  alcoholism  cause  one  another. 
FUrer  (Le  Bull.  Med.,  Aug.  25,  '95). 

[A  large  share  in  the  genesis  of  mel- 
ancholia is  due  to  agencies  lowering  the 
general  health,  among  which  alcohol  is 
conspicuous.     Farquharson  found  11  per 
cent,  of  asylum  cases  of  melancholia  due 
to   intoxicants,    while   many   victims   of 
suicidal  melancholia  who  had  no  insane 
heredity   had   a   family   history   of   ine- 
briety.    NOKMAN  Kerb,  Assoc.  Ed.,  An- 
nual, '96.] 
The  literature  of  the  past  two  years 
has    demonstrated,   more   than   that    of 
previous  periods,  perhaps,  the  pathogenic 
influence  of  alcohol  upon  the  brain.    It 
has  shown  that,  in  proportion  as  it  is 
used,  so  are  mental  disorders  prevalent, 
the  ratio  of  the  increase  of  insanity  cor- 
responding to  that  of  increased  consump- 
tion of  alcoholic  beverages. 

Neurological  and  pathological  evidence, 
together  -with  recent  experimental  work, 
show  that  in  the  early  stages  of  the 
insanities  there  is  a  profound  nutritive 
and  dynamical  failure  in  the  nerve- 
elements  of  the  brain,  which  finds  ex- 
pression in  the  insomnias,  the  melan- 
cholias, and  the  commencing  loss  of 
memory,  with  easily-induced  mental 
fatigue  which  their  subjects  experience, 
and  that  the  pathological  facts  ascer- 
tained, in  so  far  as  they  afford  us  any 
light,  force  on  us  the  conviction  that  we 
are  dealing  with  serious  nutritive  and 
dynamical  changes  in  the  central  nervous 
organ.  W.  Lloyd  Andriezen  (Quarterly 
Jour,  of  Inebriety,  Jan.,  '96). 

During  four  years,  of  2169  patients  re- 
ceived into  the  lunatic  asylum  at  Rome, 
340  (15.7  per  cent.)  owed  their  psy- 
chopathy to  alcohol:  23  per  cent,  of  the 
males,  4.6  of  the  females.  Every  form 
of  mental  disease  to  which  alcohol  may 
give  rise  is  included  in  these  340  cases. 


ALCOHOLISM.    CHRONIC.    PATHOLOGY. 


219 


all  doubtful  cases  being  carefully  ex- 
cluded. Tables  showing  that,  as  the  pro- 
duction and'  consumption  of  alcoholic 
liquors  in  Italy  generally  have  increased, 
the  number  of  insane  patients  admitted 
to  the  Roman  asylum  for  alcoholic  dis- 
eases has  grown.  A.  Volpini  (II  Poli- 
clinico,  '96). 

Alcoholism  contributed  to  the  popula- 
tion of  the  asylums  of  France,  in  1894, 
775  patients:  624  males  and  151  females. 
The  forms  in  the  males  comprised  282 
cases  of  alcoholic  delirium,  332  of  chronic 
alcoholism,  and  10  of  absinthism.  The 
females  included  90  cases  of  alcoholic  de- 
lirium, 60  of  chronic  alcoholism,  and  1 
of  absinthism.  Besides  these,  if  we  take 
account  of  the  cases  in  which  excesses  in 
drink  caused  the  entry  into  the  asylum 
of  patients  who,  without  this  cause, 
would  have  been  able  to  get  on  outside, 
we  find  further  166  males  and  63  females. 
The  two  groups — simple  alcoholic  cases 
and  the  insane  with  alcoholic  causation, 
a  total  of  1004  patients — give  a  percent- 
age of  38.42  of  the  males  and  12.82  of  the 
females  admitted.  Thus,  on  the  average, 
one-third  of  the  insanity  of  the  Depart- 
ment of  the  Seine  is  due  to  alcohol. 
Magnan   (Progres  Med.,  May  23,  '97). 

Out  of  1900  male  insane  patients 
treated  in  the  Municipal  Asylum  of 
Dresden  during  the  last  five  years,  500 
were  clearl}'  traceable  to  alcoholism. 
Luhrmann  (Archives  de  Neurol.,  No.  15, 
'97). 

In  England  drunkenness  is  increasing, 
not  only  among  the  poor,  but  also  among 
the  upper  classes,  and  especially  among 
women  of  all  classes.  Out  of  442  male 
inebriates  treated  at  the  Dalrymple 
Home  and  discharged  as  cured,  101  were 
university  men,  and  316  of  the  remainder 
were  well  educated;  235  were  married, 
and  the  others  were  widowers  or  bach- 
elors. In  228  cases  sociability  was  said 
to  be  the  cause,  ill  health  caused  the 
downfall  in  36  cases,  and  overwork  was 
■given  as  the  excuse  for  taking  to  drink 
in  32  cases.  In  55  per  cent,  of  the  cases 
the  excess  was  traceable  to  predisposing 
hereditary  causes.  About  one-third  of 
the  cases  treated  are  permanently  cured. 
Out  of  the  442  patients  discharged  from 
the  Dalrymple  Home,  372  were  kept  trace 


of,  and  of  these  149  were  said  to  be  en- 
tirely cured,  24  had  improved,  164  had 
relapsed,  31  were  dead,  and  4  were  in- 
sane. Editorial  (Med.  Record,  Sept.  25, 
'97). 

There  are  three  types  of  cell-degenera- 
tion, viz.:  (1)  intense  pigmentation  of 
the  larger  cells,  chiefly  with  degeneration 
of  the  cytoplasm;  (2)  a  general  cell- 
atrophy  of  the  body  and  nucleus;  (3) 
a  great  deal  of  change  in  the  cell-body, 
with  many  neurogliar  nuclei  in  the  peri- 
cellular spaces.  In  the  cases  of  alco- 
holism and  alcoholic  meningitis  it  was 
not  possible  to  make  out  a  distinct  type 
of  cell-degeneration,  nor  could  this  be  ex- 
pected, as  these  patients  die,  not  so  much 
fi'om  the  alcohol,  as  from  autotoxaemias 
and  from  the  febrile  process.  Charles  L. 
Dana  (Med.  News,  May  I,  '97). 

Manner  in  which  the  pathological  le- 
sions and  the  symptoms  correspond  with 
one  another:  the  sensory  disorders,  the 
exaggeration  of  the  sensibility  of  the 
skin,  the  anaesthetic  troubles,  and  the 
ocular  and  auditory  disorders  would  cor- 
respond to  the  beginning  of  the  vascular 
disorders,  when  the  nerve-cells,  irritated 
by  an  insufficient  supply  of  proper  nutri- 
ment, and  excited  by  the  presence  of  a 
poisonous  stimulus,  overact  for  the  time; 
then,  as  nutriment  is  still  withheld  from 
them,  altered  metabolism  results.  The 
beginning  sweUing  of  the  dendrites  of 
tJie  sensorimotor  region  is  marked  by 
parsesthetic  symptoms,  those  of  the  purer 
sensory  region  by  visual  and  ocular 
troubles,  and  some  amnesia,  especially 
for  recent  events;  or,  in  other  words, 
cells  that  have  the  function  of  evolving 
and  transmitting  thought  cannot  work 
properly,  and  defective  memory  results. 
Later,  as  the  motor  cells  are  more  and 
more  involved  and  nuclear  changes  Tyegin, 
continuous  tremor  becomes  apparent,  the 
muscles  no  longer  co-ordinate  perfectly, 
unless  for  a  moment  under  the  direct 
influence  of  the  will.  Still  later,  when 
a  portion  of  the  cell-structures  have  be- 
come highly  degenerated  and  the  altered 
cells  have  l)ecome  more  nimnerous,  the 
already  tottering  will-power  becomes 
more  and  more  deadened,  memory  and 
judgment  fail,  and,  when  the  degenera- 
tive process  is  far  advanced,  an  incom- 


220 


ALCOHOLISM.     CHRONIC.     TREATMENT. 


plete  dementia  is  the  final  result.  Henry 
J.  Berkley  (Johns  Hopkins  Hos.  Reports, 
vol.  vi,  '97). 

Beer.  —  Even  iTuder  the  excessive  iise 
of  malt  liquors,  subjects  rarely  fail  to 
put  on  fat.  The  blood  shows  an  increased 
proportion  of  red  and  a  diminished  pro- 
portion of  white  corpuscles.  Sudden 
cessation  of  drinking  causes  no  other 
disturbances  than  a  temporary  longing,  a 
rapid  loss  of  flesh,  and  a  decline  in  color. 
Stone  in  the  bladder  and  cystic  diseases 
are  uncommon.  Digestion  is  not  re- 
tarded. Excess  in  beer  is  apt  to  produce 
subacute  gastritis,  especially  in  the  sum- 
mer. Cirrhotic  kidney  and  hobnail  liver 
are  not  found  in  beer-drinkers.  Acute 
alcoholism  is  much  more  common  than 
delirium  tremens.    (Lambert  Ott.) 

Four  quarts  of  beer  may  be  estimated 

to   contain  240   grains  of   carbohydrates 

and     scarcely     32     grains     of    albumin. 

Striimpell  (Quarterly  Jour,  of  Inebriety, 

Jan.,  '94). 

The  diminished  vital  resistance  caused 

by  the  imbibition  of  alcohol  renders  the 

inebriate  more  liable  to  the  development 

of  disease  than  the  temperate.    Clinical 

experience    has    clearly    sustained    this 

view. 

Experience  in  India  and  other  warm 
countries  has  indicated  an  extreme  fatal- 
ity from  sun-stroke  in  persons  using 
alcohol  to  excess.  Fifty  cases  of  sun- 
stroke brought  into  the  Presbyterian 
Hospital  of  New  York. 

The  use  of  alcohol  seemed  to  have  a 
direct  unfavorable  influence.  The  habit 
was  marked  in  32  per  cent.,  moderate  in 
46  per  cent.,  denied  in  10  per  cent.;  in 
the  remaining  12  per  cent,  no  history 
could  be  obtained.  Eight  persons  were 
markedly  alcoholic  on  admission,  and  of 
these  four  died.  Editorial  (Quarterly 
Jour,  of  Inebriety,  Apr.,  '97). 

Study  of  247  recovered  personal  cases 
of  delirium  tremens:  of  these  cases  202 
were  uncomplicated  and  45  complicated 
by  other  diseases.  Twenty-two  cases 
were    complicated    by    pneumonia,    and 


when,  also,  the  lethal  cases  observed  by 
the  author  are  taken  in  account,  more 
than  12  per  cent,  of  all  eases  of  delirium 
tremens  were  combined  with  pneumonia. 
The  delirium  usually  began  on  the  fourth 
day  of  the  pneumonia,  but  the  evolution 
of  the  two  diseases  was  individual,  the 
one  in  no  way  influencing  the  other  dis- 
ease. Jacobson  (Hospitalstidende,  p.  143, 
'97). 

The  normal  vital  resistance  of  rabbits 
to  infection  by  streptococcus  pyogenes 
(erysipelatos)  is  markedly  diminished 
through  the  influence  of  alcohol  Avhen 
given  daily  to  the  stage  of  acute  intoxi- 
cation. A  similar,  though  by  no  means 
so  conspicuous,  diminution  of  resistance 
to  infection  and  intoxication  by  the 
bacillus  coli  communis  also  occurs  in 
rabbits  subjected  to  the  same  influences. 
AVhile  in  alcoholized  rabbits  inoculated 
in  various  ways  with  staphylococcus 
pyogenes  aureus,  individual  instances  of 
lowered  resistance  are  observed,  still  it  is 
impossible  to  say  from  these  experiments 
that,  in  general,  a  marked  difference  is 
noticed  between  alcoholized  and  non- 
alcoholized  animals  as  regards  infection 
by  this  particular  organism. 

It  is  interesting  to  note  that  the  re- 
sults of  inoculation  of  alcoholized  rabbits 
with    the    erysipelas    coccus    correspond 
in  a  way  with  clinical  observations  on 
human  beings  addicted  to  the  excessive 
use    of   alcohol    when    infected    by    this 
organism.    A.  C.  Abbott  (Quarterly  Jour, 
of  Inebriety,  Oct.,  '97). 
Treatment.  —  The  essential  condition 
of  cure  is  the  entire  discontinuance  of 
all  alcoholic  beverages,  whether  spirits, 
wines,    beers    and    other    malt    liquors, 
cider,  etc.    Eecords  of  reliable  scientific 
hospitals    and    homes    throughout    the 
world  show  that,  on  an  average,  fully 
one-third  of  the  cases  so  treated  have 
been  permanently  cured. 

Under  scientific  treatment  one-third  of 
inebriate  patients  are  permanently  cured. 
After  an  interval  of  from  seven  to  ten 
years,  in  two  thousand  cases  treated  at 
Fort  Hamilton,  the  proportion  was  38 
per  cent.  After  eight  to  ten  years,  35 
per  cent,  of  the  survivors  who  had  been 


ALCOHOLISM.    CHRONIC.    TREATMENT. 


221 


discharged  (numbering,  in  all,  three  thou- 
sand) from  the  Washingtonian  Home,  in 
Boston,  under  Day,  were  temperate.  Of 
two  hundred  and  sixty-si.x  who  passed 
through  the  Dalrymple  Home,  in  Eng- 
land, full  40  per  cent,  have  kept  firm. 
Crothers  (Quarterly  Jour,  of  Inebriety, 
Apr.,  '92). 

Development  of  patient's  will-power 
most  important  part  of  curative  meas- 
ures. Norton  (Brit.  Med.  Jour.,  May  25, 
'95). 

After  a  prolonged  trial  of  the  Keeley 
and  other  treatments,  that  described  by 
C.  de  Martines  was  adopted  at  the  Cery 
retreat    for   inebriates.      Almost   always 
the  patient  during  the  first  few  days  be- 
comes violently  agitated,  throws  things 
about  and  attempts  to  hurt  himself  and 
others;    so,  as  restraint  has  a  bad  effect, 
he  is  allowed  free  movement  in  a  room 
with  padded  walls  and  devoid  of  furni- 
ture.    Two  glasses   of  wine   a  day   are 
allowed  during  the  first  week  or  two,  but 
no  longer.    As  soon  as  the  mental  e.xcite- 
ment  subsides,   the   patient  is   made   to 
walk  in  fresh  air  until  tired,  and  takes 
a  warm  bath  for  half  to  one  hour  each 
day.     The  only  drugs  used  are  chloral- 
hydrate,    20    to    30    grains,    to    produce 
sleep,  preferably  given  in  a  little  wine  or 
beer,  or,  if  this  is  refused,  ^/„j  grain  of 
duboisine    or    hyoscine    hypodermically. 
Morphine  is  never  employed,  as  it  is  con- 
sidered responsible  for  many   untoward 
effects  in  the  treatment  of  these  cases. 
The   bowels    are   regulated   by   artificial 
Carlsbad  salt  or  other  saline  purgative. 
The  lungs  are  examined  every  morning, 
as  at  any  time  a  pneumonia  may  develop. 
Any  medication  is  more  rapidly  absorbed 
if  it  is  given  in  a  slightly  alcoholic  mixt- 
ure.     (Revue  Med.   de   la   Suisse   Rom., 
Mar.  20,  1900). 
There  is  no  specific.     After  treating 
the  immediate  symptoms  of  breakdown, 
delirium,  etc.,  by  flushing  the  intestinal 
canal  and  administering  food  and  effer- 
vescents  suited  to  the  harassed  and  irri- 
tated digestive  apparatus,  the  chief  drug 
reliance  should  be  on  nerve-tonics,  such 
as  strychnine  and  nux  vomica,  combined 
with   cinchona,   quinine,   iron,   chiretta. 


gentian,  and  calumba.  Complications 
must  also  be  attended  to,  as  syphilis  by 
mercury  or  potassium  or  sodium  iodide, 
and  ague  by  quinine,  bebeerine,  or  ar- 
senic. 

The   indications  are   to   prevent  the 
alcoholic  poisoning  going  further,  by  the 
immediate  withdrawal  of  alcoholic  bev- 
erages, which  superabundant  experience 
— in  prisons,  work-houses,  hospitals,  and 
homes  for  the  treatment  of  the  disease  of 
alcoholism — has  shown  to  be  quite  safe; 
to   antagonize   or   remove   the   exciting 
causes;  and  to  reconstruct  healthily  body 
and  brain.    The  highest  iniluences  of  art, 
intellect,  morals,  and  religion  should  be 
invoked   to   restore   inhibition   and  re- 
establish the  lost  will-power.     Massage, 
galvanism,  muscular  exercise,  especially 
in  the  open  air,  working  at  a  congenial 
occupation,  bathing  (including  the  Turk- 
ish or  Eoman  bath),  with  all  healthful 
and  invigorating  hygienic  exertions,  are 
useful  adjuncts  to  medicinal  therapeusis. 
The  bath  is  applied  with  advantage  to 
promote     elimination,     restore     natural 
function,    and    quiet    irritated    and    in- 
flamed organs.    Patients  debilitated  from 
acute   inflammation   and   pain   have   en- 
joyed the  bath  twice  daily  for  months. 
Shepard  (Jour.  Amer.  Med.  Assoc,  Jan. 
9,  '92). 

The  peculiarities  of  each  case  should 
be  studied,  and  it  is  important  to  instill 
into  the  alcoholist's  mind  the  necessity 
for  life-long  abstinence  from  the  toxic 
substance,  just  as  in  chronic  lead  or 
arsenic  poisoning,  with  both  of  which 
intoxications  alcoholism  has  much  in 
common. 

Strychnine  hypodermically  has  been 
recommended.  The  nitrate  or  sulphate 
is  usually  administered  in  doses  of  ^/ao 
to  ^/c  grain  daily,  or  oftener,  as  indicated 
by  the  gravity  of  the  case. 

Strychnine    used,    'As    grain    hypoder- 
mically, gradually  increasing  the  dose  till 


222 


ALCOHOLISM.     CHRONIC.     TKEATMENT. 


physiological  effects  declared  themselves, 
the  highest  dose  thus  injected  being  Vig 
grain.  At  the  same  time  Vm  grain  of 
strychnine  nitrate  is  given  by  the  stom- 
ach every  two  hours,  together  with  from 
VzK  to  Vooo  gi'ain  of  atropine  sulphate  in 
gentian  infusion.  J.  H.  Ward  (Med. 
World,  Dec,  '93). 

History  of  twenty-five  cases  of  alco- 
holic mania  treated  with  nitrate  of 
strychnine  subcutaneously  injected.  The 
dose  varied  from  Vao  to  Ve  grain  twice 
daily  for  ten  days,  then  once  daily  for 
ten  days,  the  highest  dose  being  reached 
about  the  third  or  fourth  day  and  con- 
tinued to  the  close  of  the  treatment. 
This  administration  is  in  accord  with 
Spitzka's  experiments,  that  to  maintain 
its  action  the  doses  of  strychnine  must 
be  at  first  increased;  later  the  interval 
increased  and  the  doses  lessened.  The 
border-line  of  tolerance  was  reached,  in 
most  cases,  when  15  minims  were  used 
of  a  solution  containing  2  grains  of 
strychnine  nitrate  to  4  fluidrachms  of 
water:  equal  to  Vis  grain.  Internally, 
cinchona,  peroxide  of  hydrogen,  and  cap- 
sicum were  frequently  prescribed  in  com- 
bination. When  sodium  bromide  failed 
to  procure  sleep  paraldehyde  ahvays  suc- 
ceeded. In  the  latter  case,  strychnine,  in 
doses  of  7=0  grain,  with  elixir  of  phos- 
phates and  calisaya,  was  ordered  to  be 
taken  once  or  twice  daily  for  four  to  five 
weeks  after  ceasing  the  injections.  There 
were  fourteen  relapses  known  in  these 
twenty-five  cases  from  within  one  to 
eleven  months.  Though  strychnine  is 
useful  in  restoring  temporary  health,  it 
does  not  prevent  the  possibility  of  fur- 
ther relapse.  J.  Bradford  MeConnell 
(Quarterly  Jour,  of  Inebriety,  Jan.,  '94). 

Several  cases  in  which  nitrate  of 
strychnine,  in  doses  of  from  Vso  to  ^/o 
grain,  twice  daily,  was  administered  for 
ten  days,  then  once  daily  for  ten  days, 
with  temporary  benefit.  In  many  of  the 
cases  there  was  a  relapse,  sooner  or  later, 
showing  the  need  for  prolonged  seclusion, 
with  the  operation  of  moral  and  hygienic 
conditions.  J.  Bradford  MeConnell  (N. 
y.  Med.  Jour.,  June  3,  '93). 

In  the  alcohol  wards  of  the  Bellevue 
Hospital  the  use  of  strychnine  and  the 
solanacese,  with  certain  adjuvant  tonics 


and  moral  influences,  is  employed  in 
cases  of  periodic  alcoholism.  The  drugs 
selected  are  those  which  the  experience 
of  ten  years  in  the  care  of  these  cases 
has  shown  to  be  most  useful.  Selected 
patients,  after  having  passed  through  an 
attack  of  acute  alcoholism,  and  are  con- 
valescent, are  allowed  to  remain  two 
daj's.  Only  persons  who  have  reasonable 
intelligence  and  who  show  real  evidence 
of  sincerity  are  chosen.  The  following 
solutions  are  used:  — 

li  Strychnine  nitrate.  Vis  grain. 
Atropine  sulphate,  Vsoo  grain. 
Distilled  water,  10  minims. 

M.     Sig.:     Inject  t.  i.  d. 

First  day  injection. 

B  Strychnine  nitrate,  V:o  grain. 
Atropine  sulphate,  V=oo  grain. 
Water,  10  ounces. 

M.     Sig.:    Inject  t.  i.  d. 

Second  day  injection.  C.  L.  Dana 
(Post-graduate,  July,  '96) . 

Once  insomnia  has  disappeared,  the 
propitious  moment  for  the  use  of  strych- 
nine has  arrived.  The  period  of  depres- 
sion will  be  more  or  less  prolonged;  the 
malnutrition,  already  great  during  the 
acute  attack,  will  increase;  all  the  func- 
tions will  droop  unless  a  stimulant  is 
found  to  increase  the  vital  forces,  and, 
usually,  alcohol  is  the  stimulant  instinct- 
ively sought  for  by  the  victim,  who  thus 
treads  in  a  vicious  circle.  To  avoid  this 
a  stimulant  other  tlian  alcohol  must  be 
selected  for  the  patient,  and  not  by  him: 
a  medicine,  and  not  a  sort  of  food. 
The  most  appropriate  for  this  purpose  is 
strychnine,  as  it  meets  all  the  require- 
ments rendering  its  employment  neces- 
sary. Combemale  (Le  Bull.  Med.,  Apr. 
12,  '96). 

The  principal  indication  for  the  strych- 
nine treatment  is  found  in  cases  of  con- 
firmed alcoholism  without  acute  attacks. 
But,  in  fatty  degeneration  of  the  organs, 
the  strychnine  treatment  does  not  and 
cannot  produce  any  modification  of  the 
symptoms.  It  even  constitutes  a  danger. 
Strychnine  is  slowly  eliminated  by  the 
urine,  the  saliva,  and  the  bile,  even  when 
the  organs  are  intact  and  prevent  accu- 
mulation. Hence,  cirrhosis  of  the  liver 
and  renal  impermeability  are  two  more 


ALCOHOLISM.    CHRONIC.    TREATMENT. 


223 


great  contra-indications  to  the  employ- 
ment of  this  drug.  Case  of  an  alcoholic, 
who  suflfered  from  cirrhosis  of  the  liver 
with  ascites,  in  whom  tetanic  symptoms 
occurred  after  the  fifth  injection.  Mer- 
cier  (Gaz.  Heb.  de  Med.  et  de  Chir.,  May 
16,  '97). 

Strychnine  is  a  valuable  drug  both  as 
a  tonic  and  a  stimulant,  but  should  not 
be  given  alone  except  immediately  after 
the  withdrawal  of  the  spirits.  T.  D. 
Crothers   (Penna.  Med.  Jour.,  Apr.,  '98). 

Nothing  gives  results  equal  to  strych- 
nine. One  patient  will  do  well  on  Vii 
grain,  four  times  daily;  another  will  get 
worse  on  so  small  a  dose  as  Vco  grain. 
It  is  most  important,  therefore,  to  study 
each  case.  The  proper  dose  can  usually 
be  determined  in  two  days.  Patients 
gain  from  5  to  20  pounds  in  from  three 
to  four  weeks.  If  no  improvement  oc- 
curs, either  too  much  is  given  or  not 
enough.  G.  de  Nike  (Med.  World,  Feb., 
1901). 

Having  found  liquor  ammonise  acetatis 
in  acute  alcoholism,  and  strychnine  (both 
by  the  mouth)  in  subacute  and  chronic 
alcoholism,  quite  as  effectual  as  the  sub- 
cutaneous administration,  I  eschew  the 
latter  method.  The  simpler  and  safer 
the  remedies  used,  the  more  permanent 
and  helpful  will  be  the  treatment  to  the 
sufferers. 

Hypnotism  has  been  lauded  as  a  cura- 
tive agent,  but  I  cannot  recommend  it, 
having  seen  many  cases  in  which  it  has 
failed  and  some  in  which  it  has  kft 
mental  injury.  Still  less  can  I  advise 
recourse  to  alleged  remedies,  or  remedial 
processes,  the  composition  or  particulars 
of  which  are  kept  secret.  I  have  seen 
substantial  mischief  after  the  use  of 
various  "cures"  of  this  description. 

Hypnotic  suggestion  successfully  em- 
ployed in  twenty-three  cases.  Bushnell 
(Times  and  Register,  Sept.  14,  '95). 

"Gold-cures,"  whenever  analyzed,  con- 
tain no  gold  whatever.  Gold  is  non- 
assimilable, and  inebriety  is  not  reached 
by  drugs  alone  or  by  special,  concealed 


plans  of  treatment.  In  many  cases  of 
inebriety  which  have  been  cured  in  gold- 
cure  asylums,  there  is  concealed  periodic- 
ity. There  are  no  facts  to  show  that 
gold  has  any  value  in  the  treatment  of 
this  disease.  Crothers  (Jour.  Amer.  Med. 
Assoc,  Oct.  8,  '98). 

The  strong  claims  for  the  efficacy  of 
a  remedy  for  drunkenness  led  to  a  curi- 
osity to  determine  what  it  contained. 
Some  of  these  remedies,  as  is  well 
known  to  physicians,  are  merely  alco- 
holic preparations,  others  contain  tartar 
emetic.  The  article  in  question  sells  at 
one  dollar  per  box,  containing  twelve 
powders,  weighing  about  9  grains.  The 
powder  gave  no  evidence  of  any  of  the 
ingredients  expected.  On  being  heated 
in  a  platinum  crucible,  it  charred, 
emitted  an  odor  of  burnt  sugar,  and 
finally  burned  away,  leaving  but  a  trace 
of  ash.  No  antimony  nor  mercury  com- 
pound was  present.  Ammonium  chloride 
was  detected.  There  was  no  alkaloid 
nor  alkaloidal  salt.  The  only  materials 
that  could  be  found  were  milk-sugar 
and  ammonium  chloride.  Henry  Leff- 
mann.  Laboratory  of  the  Philadelphia 
Medical  Journal  (Phila.  Med.  Jour.,  Jan. 
24,  1903). 

To  Produce  Distaste  for  Liquors.  — 
Time,  patience,  control,  and  study  of 
individual  peculiarities  are  required. 
Strychnine,  sometimes  atropine,  judi- 
ciously employed,  are  at  times  useful; 
but  there  is  no  specific. 

Small  doses  of  atropine,  less  than 
'/loo  grain,  hypodermically,  three  or  four 
times  a  day,  produce  distaste  in  from  one 
to  five  days.  Carter  (Med.  News,  Mar., 
'95). 

Same  effect  produced  by  ipecac,  20 
minims  of  the  fluid  extract  used  as  an 
hypnotic.  Waugh  (Med.  Age,  June  25, 
'95). 

To  overcome  longing  for  drink,  due  to 
irritation  of  gastric  nerve-supply:  — 

IJ  Chlorinated  water,  2  drachms. 
Decoction  of  athsea,  5  ounces. 
Cane-sugar,  2  drachms. 

M.  Sig. :  A  tablespoonful  every  two 
or  three  hours.  Zdekauer  (La  M6d. 
Mod.,  Jan.  12,  '95). 


224 


ALCOHOLISM.    CHRONIC.    TREATMENT. 


Disgusting  an  inebriate  of  alcoholic 
intoxicants -is  not  to  cure  the  disease  of 
inebrity,  or  narcomania. 

Excessive  irritatioii  following  the  re- 
moval of  alcohol  is  often  very  quickly 
removed  by  the  bromides.  They  should 
be  given  in  large  doses  of  at  least  2 
drachms  every  four  hours  in  large  quan- 
tities of  water  flavored  with  peppermint 
or  tincture  of  cinchona.  As  soon  as  the 
bromidial  effects  are  noticeable,  small 
doses  of  bitartrate  of  potassa  and  sul- 
phate of  magnesia  should  be  given,  with 
warm  shower-baths,  twice  a  day.  Bro- 
minism  is  usually  very  slight  after  this, 
and  only  the  slight  sedative  effects  re- 
main. Bromide  of  sodium  seems  to  be 
the  most  powerful  and  prompt  in  its  ac- 
tion. In  vigorous  plethoric  inebriates, 
with  a  high  degree  of  mental  irritation 
and  delirium,  the  sudden  withdrawal  of 
spirits  and  the  substitution  of  bromide 
of  sodium,  100-grain  doses  every  three  or 
four  hours,  is  followed  by  rapid  recovery. 
Many  cases  cannot  bear  the  bromides: 
they  ^eem  to  intensify  the  debility  and 
depression  from  spirits.  Chloral  should 
never  be  combined  with  bromides  for  its 
sedative  effect,  especially  in  inebriates. 
■^Tien  the  temperature '  falls  and  the 
heart  becomes  feeble,  all  bromides  should 
t)e  stopped.  When  low  muttering  de- 
lirium comes  on,  with  muscular  enfeeble- 
ment,  the  bromides  are  dangerous.  Its 
indiscriminate  use  for  all  cases  is  un- 
safe, and  its  action  should  be  watched 
■  carefully.  Editorial  (Quart.  Jour,  of  In- 
ebriety, Apr.,  '98). 

Exception  taken  to  Reid's  theory  of 
immunity  against  drunkenness  obtained 
hy  use  of  alcohol  for  successive  genera- 
tions. A  certain  degree  of  immunity  to 
the  action  of  alcohol  on  the  tissues  may 
Toe  attained,  but  not  to  the  taste  or  lik- 
ing of  alcohol.  A  direct  transmission 
of  the  taste  for  alcohol  never  occurs. 
Drunkenness  as  a  disease  is  not  trans- 
mitted, but  only  the  weakly  and  imbal- 
anced  condition  of  the  tissues  of  alco- 
holic parents.  G:  Sims  Woodhead  (Lan- 
cet, July  29,  '99). 

Conclusions  regarding  the  use  of 
apomorphine  hydrochlorate  as  hypnotic 


in  alcoholism  are:  1.  To  obtain  a  hyp- 
notic action  with  apomorphine  it  should 
be  given  hj-podermically.  2.  The  dose 
cannot  be  fixed.  It  is  best  to  begin 
with  a  small  dose, — V30  grain  or  less, — 
and  to  repeat  this  or  give  a  slightly 
larger  dose  within  a  short  time.  Fur- 
ther doses  should  not  be  given  after 
vomiting  occurs  until  several  hours  have 
passed.  3.  Doses  repeated  in  two  or 
three  hours  have  but  little  beneficial 
efi'ect.  4.  The  administration  of  apo- 
morphine should  not  be  repeated  in  pa- 
tients who  are  weak.  5.  The  duration 
of  the  hypnotic  action  is  only  a  few 
hours,  and  when  the  patient  awakes 
his  condition  is  practicallj'  unchanged, 
except  in  "ordinary  drunks."  6.  The 
best  results  are  obtained  from  apomor- 
phine when  it  is  followed  in  two  or 
three  hours  by  some  recognized  hyp- 
notic, as  bromide,  chloral,  paraldehyde, 
etc.  7.  Solutions  of  apomorphine  are 
unstable,  and  should  be  freshly  made 
for  use.  Old  solutions  should  never  be 
used.  8.  Apomorphine  may  be  employed 
as  a  hypnotic  in  selected  cases  of  alco- 
holism. The  best  results  were  obtained 
in  "ordinary  drunks"  and  in  eases  verg- 
ing on  delirium  tremens.  But  in  some 
of  these  cases  the  drug  has  no  effect 
whatever.  9.  The  administration  of 
apomorphine  to  patients  in  delirium 
tremens  was,  as  personally  observed, 
without  beneficial  result,  and  may  even 
be  attended  with  danger  from  its  de- 
pressing action.  Warren  Coleman  and 
J.  M.  Polk  (Amer.  Med.,  March  8,  1902). 

Fresh  fruits  (oranges,  etc.),  an  emetic, 
or  a  cup  of  hot  tea',  coffee,  or  cocoa  are 
frequently  sufficient  to  counteract  the 
drink  crave  or  impulse. 

For  insomnia,  hyoscine  hydrobro- 
mate,  7=00  to  Vioo  grain,  cautiously 
given,  or  a  hot,  wet  pack  is  useful. 

The  use  of  hyoscine  hydrobromate  is 
to  be  recommended,  but  its  abuse  will 
do  more  harm  than  good.  The  dose  is 
from  V300  to  ^/loo  grain,  increased  cau- 
tiously to  ^/so  grain.  Lionel  Weatherley 
(Jour,  of  Mental  Science,  July,  '91). 

Lott's  treatment  of  alcoholic  and 
morphine  habits  with  hyoscine  tried  in 


ALCOHOLISII.    PKOPHYLAXIS. 


225 


6  cases:  The  patients  can  take  massive 
doses  for  daj'S  at  a  time,  as  much  as 
'A  gi'ain  each  day  liypodermically, 
with  no  evil  effects  on  any  vital  func- 
tion. They  suffer  very  slightly,  if  at 
all,  from  the  immediate  withdrawal  of 
the  morphine.  The  desire  for  the  drug 
is  largely,  if  not  entirely,  dissipated 
after  a  few  days.  H.  A.  Hare  (Med. 
News,  June  7,  1902). 

Chloralose  has  also  been  recommended 
as  an  hypnotic  in  these  cases,  its  soothing 
effect  continuing  even  after  its  influence 
as  a  soporific  has  been  exercised. 

In  heart-failure  the  preparations  of 
ammonia,  especially  the  aromatic  spirits, 
are  effective. 

In  the  heart-failure  of  chronic  inebri- 
ates rest  in  bed  and  digitaline  granules, 
one  of  Vm  grain  being  usually  sufficient. 
Graham  Steele  (iXed.  Chronicle,  Apr., 
'93). 

Nitroglycerin  is  recommended  against 
the  vomiting  of  alcoholism.  E..  Hum- 
phreys (Brit.  Med.  Jour.,  Apr.  1,  '93). 

The  influence  of  surroundings  should 
not  be  disregarded.  The  patient  should 
be  separated  from  those  of  his  associates 
■who  cater  to  his  weakness,  and  made  to 
enjoy,  if  possible,  the  company  of  those 
who,  on  the  contrary,  tend  to  counteract 
his  habits. 

1.  The  patient  should  be  instructed  in 
regard  to  deceptive  and  injurious  influ- 
ences of  alcoholic  drinks,  so  that  he  is 
actually  convinced  that  their  use  is,  on 
all  occasions,  unnecessary.  2.  The  patient 
should  be  placed  under  good  physical  and 
social  surroundings.  For  impaired  di- 
gestion, ii-ritable  ners'ous  system,  and  dis- 
turbed sleep,  Veo  grain  of  digitaline  with 
'/so  grain  of  strychnine  at  each  meal, 
with  from  20  to  30  minims  of  diluted 
hydrobromic  acid  at  bed-time,  will  give 
excellent  results.  For  constipation,  30 
minims  of  fluid  extract  of  rhamnus  pur- 
shiana  may  be  added  to  the  acid.  In- 
stead of  the  digitalis  and  strychnine,  a 
pill  or  capsule  of  a  grain  of  extract  of 
hyoscyamus,  with  3  grains  of  cerium 
oxalate,  may  be  given.    Before  an  antici- 

1- 


pated  period  of  dissipation  a  pill  of  2 
grains  of  quinine  sulphate,  the  same 
amount  of  extract  of  eucalyptus  globu- 
lus, and  '/j  grain  of  extract  of  cannabis 
Indica  should  be  given  with  each  meal 
for  two  weeks.  3.  The  patient  should  be 
separated  from  his  associates,  and,  if  this 
cannot  be  done  in  any  other  waj',  he 
should  reside  in  a  well-regulated  a-sylum 
for  six  to  twelve  months.  N.  S.  Davis 
(Quarterly  Jour,  of  Inebriety,  Apr., '97). 

Prophylaxis. — Successful  prophylactic 
measures  must  include  power  to  compul- 
sorily  seclude  chronic  alcoholics  who  are 
too  will-paralyzed  to  apply  for  curative 
seclusion  voluntarily;  the  teaching  of  the 
young  in  the  poisoning  influence  of  alco- 
hol; the  protection  of  infants  against 
contamination  from  alcoholic  nurses;  the 
abstinence  propaganda,  especially  among 
the  rising  generations;  and  suppression 
of  the  liquor  trafBe,  either  by  a  vote  of 
localities  or  by  general  national  prohibi- 
tion. 

In  Switzerland,  in  the  Canton  of  St. 
Gall,  by  a  law  passed  in  1S91,  anyone 
rendering  himself  obnoxious  or  danger- 
ous to  Ms  family  or  to  the  community, 
through  drinking,  may,  with  a  medical 
certificate,  be  sent  to  an  inebriate  asy- 
lum, and  be  paid  for  out  of  the  public 
poor-funds,  if  his  friends  are  unable  to 
defray  the  expense.  Editorial  (Quar- 
terly Jour,   of  Inebriety,   Oct.,  '92). 

The  disorders  to  which  infants  are 
exposed  when  nursed  by  women  who 
partake  too  freely  of  stimulants — ^infant 
nervous  attacks,  convulsions,  etc. — are 
frequently  attributed  to  other  causes. 
(Vallin.) 

The  majority  of  the  posteritj'  of 
drunkards  and  of  persons  of  an  ill-bal- 
anced nervous  system  should  abstain  al- 
together from  alcohol,  or,  at  least,  be- 
fore partaking  of  it,  consult  a  com- 
petent physician.  Sir  Dyee  Duckworth 
(Lancet,  Aug.  26,  '93). 

Cases  of  alcoholism  in  children  show- 
ing importance  of  not  prescribing  alco- 
hol. Goriatchkine  (Wratsch,  No.  15, '96). 
•15 


226 


ALCOHOLISM.    MEDICO-LEGAL  CONSIDERATIONS. 


Serum-therapy  has  also  been  tried  in 
alcoholism.  The  serum  is  obtained  from 
a  horse  previously  subjected  to  a  course 
of  alcohol.  It  is  injected  hypodermic- 
ally,  80  minims  at  a  time,  every  three 
or  four  days,  until  a  peculiar  morbillic 
eruption  appears.  The  patient  is  then 
given  a  rest  of  about  a  week's  duration, 
after  which  a  final  injection  completes 
the  cure.  A  gradually  increasing  dis- 
gust or  intolerance  for  liquor  culminates 
in  an  absolute  abhorrence  of  it.  Sug- 
gestion plays  no  part  in  the  cure,  success 
having  resiilted  when  the  patient  was 
unaware  of  the  object  of  the  treatment, 
while  no  restriction  was  placed  on  the 
ordinary  habits.  Of  fifty-seven  cases 
thus  treated  by  Thiebault  (La  Tribune 
Med.,  p.  566,  1900),  all  except  those 
who  either  had  some  organic  disease  or 
else  discontinued  the  remedy  before  its 
physiological  effects  had  been  produced 
are  said  by  him  to  have  been  cured. 

Immunization  by  ethylic  alcoliol. 
Dogs  were  subjected  to  increasing  doses 
of  alcohol  administered,  well  diluted, 
through  the  oesophageal  tube  until  toler- 
ance was  established  for  a  larger  than 
an  ordinai-y  lethal  dose.  The  serum  of 
these  animals  was  employed  in  the  ex- 
perimentation. The  author  concludes 
that  (1)  it  is  possible  to  confer  a  real 
immunity  in  dogs  by  administering  pro- 
gressively increasing  doses  of  this  poison, 
ultimately  reaching  very  large  doses 
without  producing  functional  disturb- 
ances or  organic  degenerations;  (2)  the 
serum  of  such  a  dog  rendered  immune 
to  alcohol  contains  a  special  antitoxin 
capable  of  neutralizing  the  toxic  action 
of  a  dose  of  alcohol  one-fourth  larger 
than  the  minimum  fatal  dose;  (3)  nor- 
mal blood-serum  does  not  possess  the 
power  of  augmenting  the  organic  resist- 
ance to  alcohol,  much  less  to  explain  the 
curative  action  in  acute  poisoning.  Dott. 
Luigi  Maramaldi  (Gaz.  Inter,  di  Med. 
Pract,  No.  1,  p.  9,  '99). 
Medico-legal  Considerations. — Though 
there  is  some  difference  in  the  medico- 


legal treatment  of  alcoholism  in  different 
countries,  there  is  a  general  agreement 
as  to  the  form  of  civil  law  in  the 
premises. 

Insurance. — The  concealment  by  pro- 
posers and  their  referees  of  the  intoxica- 
tion of  the  assuring  may  render  a  policy 
void.  There  are  probably  at  least  600,- 
000  reformed  drunkards  in  the  world. 
Some  offices  reject  such  lives,  others 
accept  them.  The  writer  believes  that 
they  are  mostly  insurable,  after  a  certain 
term  of  years  of  abstinence,  with  a 
weighting  of  the  premium.  It  is  some- 
times difficult  to  settle  whether  a  person 
has  died  from  accident  or  from  acute  or 
chronic  alcohol  poisoning.  Insurance 
companies  lose  largely  by  the  alcoholism 
of  the  insured.  (Crothers,  Mattison, 
Fox,  Kerr.) 

Eeport  of  British  Medical  Association 
on  the  mortality  from  alcoholism,  based 
on  an  examination  of  4222  cases.  It  also 
contains  returns  as  to  the  alcoholic  habits 
of  the  inhabitants  of  Great  Britain,  and 
as  to  the  relative  alcoholic  habits  of  dif- 
ferent occupations  and  classes.  The  fol- 
lowing conclusions  reached: — 

"1.  Habitual  indulgence  in  alcoholic 
liquors  beyond  the  most  moderate 
amounts  has  a  distinct  tendency  to 
shorten  life,  the  average  shortening  be- 
ing roughly  proportional  to  tlie  degree 
of  indulgence. 

"2.  Men  who  have  passed  the  age  of 
25,  the  strictly  temperate,  on  an  average, 
live  at  least  ten  years  longer  than  those 
who  become  decidedly  intemperate.  We 
have  not,  in  these  returns,  the  means  of 
coming  to  any  conclusion  as  to  the  rela- 
tive duration  of  life  of  total  abstainers 
and  habitually  temperate  drinkers  of 
alcoholic  liquors. 

"3.  In  the  production  of  cirrhosis  and 
gout  alcoholic  excess  plays  the  very 
marked  part  which  it  has  long  been 
recognized  as  doing:  and  that  there  is 
no  other  disease  anything  like  so  dis- 
tinctly traceable  to  the  effects  of  alco- 
holic liquors. 

"4.  Apart  from  cirrhosis  and  gout,  the 


ALCOHOLISM.     MEDICO-LEGAL  CONSIDERATIOXS. 


227 


effect  of  alcoholic  liquors  is  rather  to 
predispose  the  body  toward  attacks  of 
disease  generally  than  to  induce  any 
special  pathological  lesion. 

"5.  In  the  etiology  of  chronic  renal  dis- 
ease alcoholic  excess,  or  the  gout  which 
it  induces,  probably  plays  a  special  part. 

"6.  There  is  no  ground  for  the  belief 
that  alcoholic  excess  leads  in  any  special 
manner  to  the  development  of  malignant 
disease,  and  some  reason  to  think  that  it 
may  delay  its  production. 

"7.  In  the  young  alcoholic  liquors  seem 
rather  to  check  than  to  induce  the  for- 
mation of  tubercle,  while  in  the  old  there 
is  some  reason  to  believe  that  the  effects 
are  reversed. 

"8.  The  tendency  to  apoplexy  is  not  in 
any  special  manner  induced  by  alcohol. 

"9.  The  tendency  to  bronchitis,  unless, 
perhaps,  in  the  young,  is  not  affected  in 
an}'  special  manner  by  alcoholic  excess. 

"10.  The  mortality  from  pneumonia, 
and  probably  that  from  typhoid  fever 
also,  is  not  especially  affected  by  alco- 
holic habits. 

"11.  Prostatic  enlargement  and  the 
tendency  to  cystitis  are  not  especially 
induced  by  alcoholic  excess. 

"12.  Total  abstinence  and  habitual 
temperance  augment  considerablj'  the 
chance  of  death  from  old  age  or  natural 
decay,  without  special  pathological  le- 
sion." Isamberd  Owen  (British  Med. 
Jour.,  June  23,  '89). 

Evidence. — ETidence  of  an  intoxicated 
witness  is  not  receivable. 

Confession  of  an  intoxicated  person  is 
valid,  if  no  inducement  has  been  beld 
out  (England). 

Contracts  executed  while  intoxicated 
are  voidable. 

Wills  made  while  intoxicated  have 
been  voided.  Intoxication  and  incapac- 
ity, it  was  held,  must  be  complete,  till 
1892  (Tyler  v.  Maxwell,  Court  of  Session, 
Edinburgh,  Nov.  1,  1892),  when  Lord 
Wellwood  ruled  that  the  defensive  plea 
of  intoxication  having  to  be  total,  though 
true  in  a  sense,  did  not  mean  total  dis- 
ablement by  drink.     And  (Morgan  and 


another  v.  Kitchen,  Probate  and  Divorce, 
High  Court,  London,  1891),  though  a 
first  will  was  held  good,  one  executed  a 
year  later  was  pronounced  bad,  on  the 
ground  that  the  testator  had  (though  not 
intoxicated  when  he  made  the  second 
disposition)  become,  after  the  earlier 
date,  mentally  incapacitated  after  fre- 
qiient  (not  intoxication  but)  "taking  his 
drops,'"  and  after  deliriiim  tremens.  At- 
testation is  invalid  if  done  by  an  intoxi- 
cated attestator,  but  presumption  is  in 
favor  of  validity. 

Criminal  Jurisprudence. — Under  Greek 
law  crime  committed  in  intoxication  was 
liable  to  double  punishment.  Eoman  law 
remitted  capital  punishment  to  intoxi- 
cated soldiers.  Mohammedan  law  does 
not  admit  a  plea  of  intoxication.  New 
York  Penal  Code  holds  no  act  less  crim- 
inal by  having  been  committed  while 
intoxicated,  but  intoxication  considered 
to  determine  purpose,  motive,  and  intent. 
Voluntary  intoxication  is  not  a  defense 
in  homicide  without  provocation.  De- 
lirium tremens,  as  a  disease  secondary  to 
voluntary  intoxication,  has  been  accepted 
in  many  trials  in  England  and  the  United 
States  as  a  valid  plea  for  irresponsibility 
(Justice  Stephen,  Newcastle,  1881;  Jus- 
tice Hawkins,  Shrewsburj',  1895),  though 
this  ruling  has  not  been  followed  by 
some  other  judges.  In  other  trials  the 
accused  has  been  acquitted  as  having 
been  unable,  from  intoxication,  to  have 
been  capable  of  any  intent,  or  as  having 
been  the  subject  of  a  well-defined  mental 
disease,  as  having  (through  inherited  or 
acquired  mental  weakness)  been  unable 
to  drink  intoxicants  without  insane  se- 
quelaa  like  the  average  man.  English 
law  also  takes  drunkenness  into  account 
(Lord  James)  "if  it  produces  a  sudden 
outbreak  of  passion  causing  the  commis- 
sion of  crime  under  circumstances  which, 
in  a  sober  person,  would  reduce  a  charge 


228 


ALCOHOLISM.    MEDICO-LEGAL  CONSLDERATIONS. 


of  murder  to  manslaughter."  Altogether 
there  has  generally  been  a  growing  tend- 
ency of  judges  and  juries  to  take  alco- 
holism (with  mental  disturbance)  into 
account,  during  the  past  thirty  years. 
German  and  Swiss  law  prescribes  a  dif- 
ference in  the  punishment  of  offenses 
committed  in  culpable  and  inculpable 
intoxication. 

Minor  Offences.  —  In  theft  and  other 
minor  offences,  in  England,  committed 
in  alcoholism,  intoxication  and  delirium 
tremens  have  been  accepted  as  an  answer 
in  some  cases,  while  many  such  offenders 
have  been  liberated,  to  come  up  on  their 
own  recognizances  with  a  limited  time  if 
called  on,  on  the  understanding  that 
they  would  forthwith  go  to  a  Home  for 
Inebriates. 

Inebriety  is  a  disease  of  the  brain,  a 
form  of  insanity  wholly  dominating  the 
volition,  and  beyond  the  power  of  the 
victim  to  control.  Clark  Bell  (Medico- 
Legal  Jour.,  Dec,  '92). 

The  affirmation  of  irresponsibility 
should  involve  prolonged  commitment  to 
an  insane  asylum.  Motet  and  Vidal 
(Quarterly  Jour,  of  Inebriety,  Jan.,  '93). 
The  knowledge  of  right  and  wrong 
may  exist  without  the  power  of  discrimi- 
nating between  the  two.  T.  L.  Wright 
<  Quarterly  Jour,  of  Inebriety,  Jan.,  '93). 
Criminal  acts  come  from  inability  to 
understand  the  relation  of  surroundings, 
and  to  adjust  the  conduct  to  the  vary- 
ing conditions  of  life.  The  criminal  acts 
of  the  inebriate  spring  from  this  con- 
fusion of  senses  and  judgment.  This 
shows  the  irresponsibility  of  inebriates. 
T.  D.  Crothers  (Quarterly  Jour,  of  Ine- 
briety, Jan.,  '93). 

At  meetings  of  creditors,  by  the  au- 
thor's advice,  legal  advisers  have  re- 
frained from  calling  as  witnesses  persons 
whose  brains  had  been  so  affected  by 
intoxicants  as  to  dim  the  perception  of 
truth  and  render  their  evidence  value- 
less. Norman  Kerr  ("Inebriety,"  third 
edition) . 

By  existing  British  law,  habitual 
drunkenness,  as  such,  forms  no  defense. 


either  in  civil  or  criminal  cases,  except 
in  so  far  as  it  may  be  admissible  as  evi- 
dence with  a  view  to  prove  facts  which 
can  be  construed  as  establishing  legal 
incapacity  or  insanity.  J.  R.  Mcllraith 
(Proceedings  of  the  Soc.  for  the  Study 
of  Inebriety,  Aug.,  '93). 

Statistics  based  on  1500  cases  (1200 
men  and  300  women)  of  alcoholic  in- 
sanity having  required  entrance  into  an 
asylum  show  that  more  than  two-fifths 
of  delirious  alcoholic  patients  had  com- 
mitted crimes  or  misdemeanors.  Of  these 
acts  the  most  frequent  are  those  directed 
against  the  life,  and  especially  attempts 
of  suicide.     Serre  (Paris  Thesis,  '96). 

In  some  of  the  more  recent  trials 
certain  diseased  inebriate  mental  states, 
short  of  what  is  generally  regarded 
legally  as  insanity,  have  granted  exemp- 
tion from  responsibility.  This  recogni- 
tion of  such  abnormal  mind  conditions 
as  a  legal  answer  has,  however,  had  to 
be  entered  as  a  plea  of  insanity  and  not 
inebriety.  It  is  greatly  to  be  desired,  in 
the  interests  alike  of  equity  and  justice, 
that  certain  abnormal,  inebriate,  disor- 
dered mental  states  should  be  accepted 
as  a  valid  plea  altogether  from  the  stand- 
point of  insanity.  The  alternative  would 
be  the  classification  of  such  pathological 
states  of  mind  as  a  variety  of  mental 
unsoundness,  as  in  Belgian  law.  The 
former  method  of  a  distinct,  independ- 
ent, legal  recognition  is,  however,  pref- 
erable, if  for  no  other  reason  than  that 
the  inebriate  should  not  be  associated  in 
treatment  with  the  insane. 

On  the  first  of  January,  1900,  all  the 
German  States  will  have  a  common  civil 
law.  The  sixth  paragraph  of  the  new 
Code  runs  thus:    The  Interdicted  can  be: 

1.  He  or  she  who,  in  consequence  of 
mental  insanity  or  mental  weakness,  can- 
not provide  for  his  or  her  affairs. 

2.  He  or  she  who  brings  himself  or  his 
family  into  the  danger  of  need  by  prodi- 
gality. 

3.  He  or  she  who,  in  consequence  of 
inebriety,  cannot  provide  for  his  affairs, 


ALCOHOLISM. 


ALKALOIDS. 


229 


or  brings  himself  or  his  family  into  the 
danger  of  need  or  endangers  the  safety 
of  others. 

The  interdiction  is  to  be  revoked  as 
soon  as  the  reason  for  interdiction  ceases 
to  exist.  William  Bode  (Proceed,  of  the 
Soc.  for  the  Study  of  Inebriety,  Nov., 
'97). 

NOEIIAN  KeKE, 

London. 

ALEXIA.     See  Aphasia. 

ALKALOIDS.  —  The  alkaloids  are  or- 
ganic basic  substances,  the  active  prin- 
ciples of  most  poisonous  plants.  They 
are  termed  "alkaloid"  owing  to  their  be- 
havior with  acids,  which  simulates  that 
of  alkaline  substances:  ammonia,  etc. 
Combining  with  acids  they  form  salts 
which  are  convenient,  owing  to  the 
smallness  of  their  doses  and  their  com- 
parative precision  as  to  the  effects  to  be 
produced. 

Dose  ajid  Properties. — A  point  of  im- 
portance in  prescribing  alkaloids,  when 
they  are  administered  in  tablet  form,  is 
to  avoid  too  rapid  drying  of  the  tablets, 
the  preparation  otherwise  becoming  de- 
teriorated. 

Case    showing   that    certain    alkaloids 
are  so  delicate  that  thej'  are  injured  if 
the   tablets   are    dried   too   quickly.      A 
prescription  of  his,  calling  for  a  tablet 
of    hyoscyine,    morphine,    and    atropine, 
was  dried  in  a  half-hour  instead  of  a  day 
and  a  half,  as  recommended  to  him  by 
druggists.     J.  A.   Cutter    (Medical   Bul- 
letin, June,  '90). 
The  following  alkaloids  are  official  in 
the  United   States  Pharmacopceia,  but 
many  others  are  employed  that  will  be 
considered  imder  their  appropriate  head- 
ings:— 

Apomorphine  hydrochlorate,  dose,  ^/le 
to  V4  grain. 

Atropine,  dose,  ^/ooo  to  '/oo  grain. 
Atropine  sulphate,  dose,  V200  to  Vco 
grain. 


Caffeine,  dose,  2  to  10  grains. 

Caffeine  citrate,  dose,  2  to  5  grains. 

Caffeine  effervescent  citrate,  dose,  1  to 
3  drachms. 

Chinoidine,  dose,  3  to  30  grains. 

Cinchonidine  sulphate,  dose,  5  to  40 
grains. 

Cinchonine,  dose,  5  to  30  grains. 

Cinchonine  sulphate,  dose,  5  to  30 
grains. 

Cocaine  hydrochlorate,  dose,  Vj  to  2 
grains. 

Codeine,  dose,  ^/^  to  2  grains. 

Hydrastine  hydrochlorate,  dose,  '/j 
grain. 

Hyoscine  hydrobromate,  dose,  V150  to 
Vioo  grain. 

Hyoscj'amine  hydrobromate,  dose,  Vsi 
to  V32  grain. 

Hyoscyamine  sulphate,  dose,  Veo  to 
V3„  grain. 

Morphine,  dose,  ^/lo  to  ^7,  grain. 

Morphine  acetate,  dose,  ^/^  to  ^/j 
grain. 

Morphine  hydrochlorate,  dose,  ^/g  to 
^/j  grain. 

Morphine  sulphate,  dose,  ^/^  to  ^/z 
grain. 

Physostigmine  salicylate,  dose,  Vei  to> 
V20  grain. 

Physostigmine  sulphate,  dose,  Vioo  to 
Vso  grain. 

Pilocarpine  hydrochlorate,  dose,  V12 
to  V3  grain. 

Piperine,  dose,  ^/^  to  10  grains. 

Quinidine  sulphate,  dose,  5  to  30 
grains. 

Quinine,  dose,  1  grain  to  1  drachm. 

Quinine  bisulphate,  dose,  1  to  15 
grains. 

Quinine  hydrobromate,  dose,  1  to  20 
grains. 

Quinine  hydrochlorate,  dose,  1  to  15 
grains. 

Quinine  sulphate,  dose,  1  grain  to  1 
drachm. 


230 


ALKALOIDS.    PHYSIOLOGICAL  ACTION. 


Quinine  valerianate;  dose,  1  to  20 
grains. 

Sparteine  sulphate,  dose,  Vs  to  1 
grain. 

Strychnine,  dose,  ^/gg  to  '^/jo  grain. 

Strychnine  sulphate,  dose,  Vgo  to  ^/^o 
grain. 

Veratrine,  dose,  ^/^o  to  V30  grain. 

Physiological  Action. — Alkaloids  have 
various  degrees  of  physiological  activity 
when  introduced  into  the  animal  body. 
Many  are  slow  in  their  action,  and  a 
large  dose  is  required  to  produce  any 
observable  efEeet,  while  others  act  more 
rapidly,  and  are  so  potent  that  even  a 
minute  dose  may  destroy  life.  Compare, 
for  example,  narcotine,  one  of  the  al- 
kaloids of  opium,  with  nicotine,  the  alka- 
loid of  tobacco.  Twenty  to  30  grains 
of  the  former  have  been  taken  by  the 
hiTman  subject  without  producing  any 
marked  symptoms,  while  the  twentieth 
part  of  a  grain  of  the  latter  may  induce 
symptoms  so  severe  as  to  threaten  death. 
It  is  also  well  known  that  alkaloids 
may  have  a  different  kind  of  action  on 
difEerent  animals.  Thus,  ^/^  grain  of 
atropine  will  produce  serious  symptoms 
of  a  complex  character  in  a  dog,  while 
3  or  even  4  grains  may  be  given  to  a 
rabbit  without  causing  any  more  marked 
effect  than  dilatation  of  the  pupil.  In 
considering  the  physiological  actions  of 
those  substances,  the  following  general- 
ization may,  in  the  present  state  of 
science,  be  made  tentatively:  1.  As  a 
general  rule,  the  more  complex  the  or- 
ganic molecule,  and  the  greater  the  sum 
of  its  atomic  weight,  the  more  intense 
will  be  the  action  of  the  substance.  2. 
Substances  that  split  up  quickly  into 
simpler  bodies  produce  rapid,  but  tran- 
sient, physiological  effects,  whereas  sub- 
stances which  resist  decomposition  in 
the  blood  or  tissues  may  produce  no 
appreciable  results  for  a  time,  but,  when 


they  do  begin  to  break  up,  the  effects  are 
sudden  and  violent,  and  usually  last  for 
a  considerable  time.  3.  Alkaloids  have 
frequently  a  double  action  on  different 
parts  of  a  great  physiological  system; 
and  their  action  in  a  particular  group  of 
animals  will  depend  on  the  relative  de- 
gree of  development  of  the  parts  of  the 
system  in  that  group.  Thus  most  of  the 
alkaloids  of  opium  have  such  a  double 
action:  a  convulsive  action  resembling 
that  of  strychnine,  due  to  their  influence 
on  the  spinal  cord  or  on  the  motor  cen- 
tres in  the  brain;  and  a  narcotic,  or 
soporific,  action  resembling  that  of  anaes- 
thetics, due  to  their  influence  on  sensory 
centres  in  the  brain.  Hence,  in  animals, 
where  the  spinal  system  predominates,  as 
in  frogs,  these  alkaloids  act  as  convul- 
sants;  while  in  the  higher  mammals 
their  principal  action  is  apparently  on 
the  encephalic  centres,  which  have  now 
become  largely  developed.  (J.  G.  Mc- 
Kendrick.) 

Besides  the  individual  physiological 
properties  of  alkaloids  (these  will  be 
described  under  their  respective  head- 
ings), a  few  possess  a  property  in  com- 
mon: that  of  reducing  temperature  when 
applied  to  the  surface.  This  question 
was  studied  by  Guinard  and  Geley,  of 
Lyons.  Of  eighteen  substances  tried  by 
the  authors  in  solution  or  as  ointments 
applied  on  the  inner  part  of  the  thighs, 
four  were  found  to  possess  a  constant 
regulating  effect  upon  thermic  reaction. 
These  were  cocaine,  solanine,  sparteine, 
and  helleborine.  In  cases  of  true  hyper- 
pyrexia a  lowering  of  from  0.9°  to  5.4° 
F.  was  produced,  the  average  fall  being 
from  1.8°  to  2.7°  F.,  the  effect  varying 
according  to  the  patient,  and  especially 
according  to  the  disease.  They  produced 
a  more  marked  change  at  the  beginning 
and  end  of  acute  affections  than  in  the 
middle  of  the  attack,  and  in  mild  rather 


ALKALOIDS. 


ALOES. 


231 


than  in  grave  forms.  In  healthy  sub- 
jects the  effects  were  less  apparent.  It 
may  be  hoped  to  influence  the  tempera- 
ture in  this  manner  without  administer- 
ing the  remedy  internally. 

Therapeutics.  —  As  these  agents  are 
extensively  administered  hypodermically, 
it  was  at  one  time  feared  they  might 
serve  as  vehicles  for  micro-organisms 
which  in  themselves  might  become  pa- 
thogenic. In  a  series  of  experiments 
having  for  their  object  to  answer  these 
questions  and  to  determine  a  method  for 
the  sterilization  of  such  medicines  Mari- 
nucci  found  (1)  that,  while  all  prepara- 
tions studied  contained  microbes,  all 
these  microbes  are  not  harmful.  (2) 
That  sterilization  by  heat  does  not  alter 
solutions  of  strychnine,  curare,  bihydro- 
chlorate  of  quinine,  or  borate  of  eserine. 
It  enfeebles,  but  does  not  alter,  the  char- 
acter of  morphine  and  atropine.  After 
sterilization,  however,  these  drugs  must 
be  used  in  larger  doses.  The  sulphate  of 
eserine  was  found  to  be  seriously  altered, 
so  that  the  solutions  were,  in  a  great 
measure,  rendered  inert.  (3)  That,  to 
those  solutions  which  are  altered  by  heat, 
corrosive  sublimate  should  be  added  in 
the  proportion  of  1  to  10,000.  This 
seems  to  be  eiiicacious,  and  in  no  way  to 
injure  the  value  of  the  alkaloid  when 
given  hypodermieally. 

Legal  Medicine. — In  medical  juris- 
prudence alkaloids  often  come  into  play, 
the  smallness  of  the  dose  of  many  of 
these  salts  serving  the  purpose  of  evil- 
doers or  suicides.  By  well-known  means 
their  presence  may  be  determined  in  the 
majority  of  cases;  but  still  obscure  in 
this  connection  is  the  influence  of  putre- 
factive processes — such  as  those  which 
take  place,  after  death,  in  the  body — 
upon  alkaloids  which  may  have  been 
administered  during  life.  Ottolenghi 
recently  conducted  a  number  of  experi- 


ments in  order  to  ascertain  the  action  of 
saprophytic  micro-organisms  on  atropine 
and  strychnine.  lie  first  tried  the  effect 
of  adding  a  known  quantity  of  atropine 
to  some  sterilized  bouillon  (1  to  10,000), 
which  was  afterward  tested  by  dropping 
a  couple  of  drops  of  it  into  a  rabbit's  eye. 
The  usual  effects  of  atropine  ensued:  the 
pupil  dilated  fully  under  the  influence 
of  the  unaffected  atropine.  He  then 
substituted  for  the  sterilized,  bouillon 
separate  cultures,  in  bouillon,  of  bacillus 
mesentericus,  bacillus  vulgatus,  bacillus 
liquefaciens  putridus,  bacillus  subtilis, 
and  bacillus  diffusus,  which  he  had  ob- 
tained from  a  human  cadaver,  the  result 
being  that  the  mydriatic  eifect  of  the 
atropine  was  entirely  destroyed  in  four 
or  five  days  by  the  action  of  the  micro- 
organisms. A  similar  series  of  experi- 
ments were  made  with  strychnine,  the 
test  for  the  alkaloid  being  that  of  inject- 
ing a  certain  quantity  of  the  solution 
into  a  frog,  the  quantity  being  propor- 
tionate to  the  weight  of  the  frog.  It  was 
found  that  for  the  first  few  days  the 
toxic  action  of  the  strychnine,  subjected 
to  the  influence  of  the  bacteria,  was 
distinctly  increased;  subsequently  it  was 
diminished.  Some  separate  experiments 
made  with  cultures  of  bacillus  coli  and 
strychnine  showed  that,  with  this  bac- 
terium, the  toxicity  of  the  alkaloid  ma- 
terially diminished  from  the  first.  After 
an  exposure  of  three  months  the  alkaloid 
had  lost  one-half  of  its  potency.  (J. 
Dixon  Mann.) 

ALOES.  —  The  preparations  of  aloes 
employed  in  the  United  States  are  ob- 
tained from  two  varieties:  the  Aloe  Bar- 
hadensis,  or  Vera,  and  the  Aloe  Socotrina. 
The  former  is  the  inspissated  juice  of 
the  Barbadoes,  or  Curacoa,  aloes  and  oc- 
curs in  orange-brown,  opaque,  resin-like 
masses  that  give  off  an  odor  of  saffron, 


232 


ALOES.    ALOIN. 


and  are  extremely  bitter  to  the  taste. 
The  Socotrine  aloes  is  the  inspissated 
juice  of  the  Aloe  Perryi.  It  varies  in 
color  from  a  yellowish  brown  to  an 
opaque,  reddish  brown  and  also  occurs 
in  resinous  masses  and  emits  the  same 
safEron-like  ordor  and  is  as  bitter  to  the 
taste. 

1.  Curagoa  aloes  are  as  eiBcient  as  and, 
being  much  cheaper,  should  be  preferred 
to  Socotrine  aloes;  the  greater  portion 
of  the  latter  as  sold  to-day  is  made  up 
of  the  former.  2.  The  resin  of  aloes  is 
an  ether  or  organic  salt,  and  varies  ac- 
cording to  the  kind  of  aloes  and  the 
varying  constituents  of  the  acid,  the  al- 
coholic constituent  being  aloresinotannol, 
and  being  the  same  in  both  Barbadoes 
and  Cape  aloes:  the  only  specimens  thus 
far  examined.  3.  Aloin  contains  emodin, 
to  which  its  laxative  properties  are  prob- 
ably due.  4.  Many  laxative  drugs  beside 
aloes — such  as  senna,  cascara  sagrada, 
rhubarb,  buckthorn-bark — owe  their  lax- 
ative property  to  this  substance,  emodin, 
or  some  substance  like  it,  derived  from 
anthraquinone,  and  homologous  or  iso- 
meric with  it.  A.  E.  L.  Dohme  (Amer. 
Jour,  of  Pharm.,  No.  8,  '98). 

Dose. — Both  varieties  of  aloes  may  be 
given  in  doses  of  from  1  to  5  grains  as 
a  laxative,  and  10  grains  as  a  purgative. 
The  purified  aloes  {aloes  purificata)  of 
the  U.  S.  P.  should  invariably  be  pre- 
scribed, since  the  commercial  aloes  con- 
tains impurities.  The  other  official  prep- 
arations of  aloes  are  the  following: — • 

Aqueous  extract  of  aloes.  Dose,  ^/n  to 
5  grains. 

Pill  of  aloes  containing  2  grains  of  the 
purified  aloes. 

Pill  of  aloes  and  asafoetida,  containing 
1  Va  grains  of  each  drug  to  the  pill. 

Pill  of  aloes  and  iron,  containing  puri- 
fied aloes,  sulphate  of  iron,  and  aromatic 
powder,  1  grain  of  each  to  the  pill. 

Pill  of  aloes  and  mastic  (Lady  "Webster 
pill),    containing    2    grains    of   purified 


aloes  and  V2  grain  each  of  mastic  and 
red  rose. 

Pill  of  aloes  and  myrrh,  containing  2 
grains  of  purified  aloes,  1  grain  of  myrrh, 
and  ^/j  grain  of  aromatic  powder  per  pill. 

Tincture  of  aloes  and  myrrh,  contain- 
ing 10  per  cent,  purified  aloes.  Dose, 
1  to  8  drachms. 

Tincture  of  aloes,  containing,  also,  10 
per  cent,  of  purified  aloes.  Dose,  1  to  2 
drachms. 

Aloes  acts  slowly;  it  can,  therefore, 
be  given  at  bed-time  and  its  effects  be 
counted  on  for  the  next  morning.  It 
tends  to  cause  griping;  a  carminative 
— belladonna  or  hyoscyamus — should, 
therefore,  be  simultaneously  adminis- 
tered. The  pill  of  aloes  and  myrrh  of 
the  U.  S.  P.  is  intended  to  avoid  this 
untoward  effect  of  aloes. 

Applied  to  a  wound  in  the  form  of 
powder  aloes  exercises  its  laxative  action. 
It  also  acts  upon  a  nursing  infant  when 
given  to  the  mother. 

Aloin. 

Aloin  is  the  active  principle  of  aloes. 
The  drug  extracted  from  the  Barbadoes 
aloes  is  identical  with  that  taken  from 
the  species  of  Curagoa  and  Natal.  Aloin 
occurs  in  yellowish-white,  acicular  crys- 
tals, is  soluble  in  hot  water  and  alcohol, 
much  less  so  in  acetic  ether,  and  spar- 
ingly soluble  in  chloroform,  ether,  and 
benzol. 

Dose. — The  dose  of  aloin  is  from  ^/jo 
grain  to  2  grains. 

Physiological  Action.  —  The  main  ef- 
fect of  aloes  is  upon  the  large  intestine, 
but  it  is  likewise  a  cholagogue,  actively 
promoting  the  flow  of  bile.  These  effects, 
combined,  cause  increase  of  the  peristal- 
tic action  of  the  bowel.  Aloes  causes 
engorgement  of  the  hsemorrhoidal  blood- 
vessels and  thus  tends  to  render  hffimor- 
rhoids  painful  at  the  time  it  is  used,  if 
any  be  present.    The  other  pelvic  organs 


ALOES. 


233 


— the  uterus  and  appendages — are  also 
congested.  Hence,  pregnant  women 
should  use  aloes  most  carefully,  if  at 
all. 

The  active  principle,  aloin,  acts  as 
a  po\Yerful  purgative  when  given  by  the 
mouth  or  subcutaneously.  Natal  aloin 
acts  in  cats  and  dogs  only  after  very  large 
quantities,  but  the  effects  are  promptly 
produced  when  an  alkali  is  added  to  the 
drug  in  order  to  decompose  it.  In  man 
fed  on  meat  exclusively  aloin  is  very 
active,  but  not  so  in  persons  subjected 
to  a  mixed  diet.  Aloin  in  itself,  there- 
fore, has  little  or  no  purgative  properties, 
and,  in  order  to  produce  its  characteristic 
effects,  it  must  undergo  decomposition  in 
the  intestines  and  a  new  and  more  active 
substance  be  formed.  The  slowness  of 
its  action  is  thus  explained.     (Meyer.) 

Therapeutics.' — It  is,  of  course,  in  con- 
stipation that  aloes  is  especially  used. 
It  is  indicated  when  there  is  intestinal 
atony,  but  when  its  administration  is 
prolonged  it  tends  to  aggravate  the 
condition  it  is  intended  to  counteract. 
Aloin  possesses  two  advantages  over 
aloes,  namely:  smaller  doses  and  com- 
paratively slight  tendency  to  induce  ir- 
ritation in  normal  doses.  It  is  usiially 
combined  with  extract  of  belladonna  and 
nux  vomica  or  strychnine  in  small  doses. 
An  active  laxative  pill  is  thus  obtained, 
which  tends  to  counteract  constipation 
without  overtaxing  the  normal  functions 
of  the  intestine. 

Chlorosis. — In  chlorosis  aloes  is  usu- 
ally combined  with  iron:  the  pill  of  aloes 
and  iron  of  the  U.  S.  P.  It  is  best, 
however,  not  to  use  this  pill,  owing  to 
the  constipating  effect  of  the  preparation 
of  iron  utilized  in  it.  The  pyrophos- 
phate of  iron  or  dialyzed  iron  is  to  be 
preferred. 

AiiEXOKEHCEA. — When  this  condition 
is  due  to  ansemia  a  pill  of  aloes  and  pyro- 


phosphate of  iron  is  of  great  value.  In 
uncomplicated  cases  the  pill  of  aloes  and 
myrrh  is  to  be  preferred,  the  congestive 
influence  of  the  active  drug  tending 
greatly  to  facilitate  physiological  men- 
struation. 

H^MOHEHOiDS. — Aloes  is  said  by  some 
to  be  valuable  in  this  disorder,  especially 
when  due  to  general  relaxation  of  the 
vascular  system,  the  haemorrhoidal  veins 
bearing  the  brunt  of  the  latter. 

ALOPECIA.— From  Gr.,a?.(j7t>7^,fos. 
Definition.- — Partial  or  general  falling 
of  the  hair  while  the  pathological  proc- 
ess is  in  progress. 

Varieties.  —  Alopecia  may  be  physio- 
logical or  be  due  to  an  acute  or  chronic 
general  morbid  state.  It  may  be  eon- 
genital  or  occur  as  a  consequence  of  old 
age.  Senile  alopecia,  when  occurring  in 
younger  individuals,  without  apparent 
lesion,  is  recognized  as  premature  alo- 
pecia. 

Pathological  alopecias,  due  to  a  gen- 
eral morbid  condition,  may  be  acute  or 
chronic. 

The  acute  form  presents  itself  espe- 
cially during  the  recovery  from  scarlet 
fever,  scarlatinoid  erythema,  small-pox, 
typhoid  fever,  and  child-birth.  Certain 
forms  of  rapid  alopecia  are  due  to  un- 
known causes  of  nervous  origin. 

Neurotic  alopecia  is  a  rare  affection. 
Two  varieties  are  to  be  noted.  The  par- 
tial neurotic  alopecia  that  occurs  in  the 
area  of  distribution  of  a  nerve  aft«r  an 
injury  of  that  structure  is  occasionally 
seen.  General  and  complete  alopecia 
from  neurotic  causes  is  even  less  com- 
mon. In  almost  every  case  a  severe 
nervous  shock  precedes  the  falling  of  the 
hair.  Illustrated  case.  William  S.  Got- 
theil   (Med.  Record,  Aug.  21,  '97). 

There  are  two  distinct  forms:  1.  Occip- 
ital baldness,  which  is  common  in  young 
people,  begins  over  the  occiput,  extend- 
ing slowly,  is  rarely  contagious,  and  is 


234 


ALOPECIA.    SYMPTOMS. 


curable.  2.  Seborrhoeic  alopecia  (of  Bate- 
man)  which  appears  in  adult  and  middle 
life.  The  original  area  is  succeeded  by 
secondary  patches  at  soine  distance.  It 
is  due  to  a  microbic  infection  of  the 
seborrhtEic  glands,  and  is  but  slightly 
contagious.  M.  Sabouraud  (Jour,  des 
Pratieiens,  Sept.  29,  1900). 

The  chronic  variety  may  be  due  either 
to  want  of  care  of  the  hair;  bad  cos- 
metics; heavy  hats;  poor  general  hy- 
giene; lack  of  sleep;  excesses;  poor  food; 
poor  constitution;  arthritism;  struma; 
chronic  poisoning  (mercury);  ansmia 
and  chlorosis;  diabetes;  phthisis;  cancer; 
syphilis;  leprosy;  in  the  two  latter  with 
or  without  visible  lesions. 

Alopecia  may  also  be  due  to  a  local 
disease  of  the  scalj),  and  occurring  in 
that  case  as  one  of  the  secondary  phe- 
nomena of  the  chief  affection.  The 
principal  affections  in  which  alopecia 
may  thus  occur  are  erysipelas,  eczema, 
seborrhoeic  eczema,  psoriasis,  lichen, 
pityriasis  rubra,  pemphigus  foliaceus, 
impetigo,  acne  (atrophic  acne),  sycosis, 
lupus  erythematosus,  and  scleroderma. 

In  another  class  of  affections  alopecia 
occurs  as  the  principal  symptom,  namely: 
seborrhoea,  pityriasis  capillitii,  etc.;  fol- 
liculitis due  to  drugs;  keratosis  pilaris; 
alopecia  areata;  trieophytosis,  and  favus. 
(Brocq.) 

There  are  also  indefinite  varieties: 
such  as  the  form  due  to  a  constant 
scratching  of  the  head:  the  tricho- 
mania  of  Besnier. 

That  occurring  in  weak  and  hydro- 
cephalic children  from  constant  pressure 
of  the  head  of  the  bolster. 

Alopecia  of  the  vertex  in  women,  due 
to  combs  and  hair-pins,  is  also  classed 
among  the  indefinite  varieties. 

A  variety  of  alopecia  which  occurs 
rapidly,  but  only  temporarily,  is  fre- 
quently observed  in  connection  with 
menstrual  disturbances  in  women. 


Symptoms.  —  Congenital  Alopecia.  — 
This  form  of  alopecia  is  uncommon; 
it  may  be  local  or  general,  temporary 
or  permanent.  Keratosis  pilaris  and 
moniliform  aplasia  may  coincide  with  it. 
It  may  be  due  to  lack  of  development 
of  the  hair-follicles,  due  to  backwardness 
in  the  development  of  the  hair;  or  to  a 
pathological  condition  occurring  during 
intra-uterine  life,  ichthyosis,  xeroderma, 
or  trophoneurosis.  Congenital  alopecia 
is  frequently  associated  with  slow  and 
late  dentition. 

Senile  Alopecia. — Senile  alopecia  may 
begin  at  45  or  50  years.  The  hairs  first 
become  gray,  then  white,  dry  up,  and 
their  root  atrophies.  They  finally  fall, 
while  the  scalp  shows  the  signs  of  senile 
cutaneous  atrophy. 

This  form  usually  begins  at  the  vertex, 
rarely  at  the  temples. 

Senile  and  precocious  alopecia  ig  usu- 
ally severe  and  progressive.     It  is  con- 
fined  to   the   antero-superior   portion    of 
the  scalp,  beginning  on  the   top  of  the 
cranium  and  moving  forward,  leaving  a 
little   tuft  of   hair   above    the   forehead. 
The  posterior  and  lateral  portions  of  the 
scalp  preserve  their  hair  almost,  or  quite, 
intact.     Fournier    (La   Med.   Mod.,  Dec. 
11,  '90). 
Alopecia  Following  Acute  and  Chronic 
General  Diseases.  —  Though  usually  not 
marked,  alopecia  in  these  cases  may  be 
intense  and  general.     Seborrhoea  is  fre- 
quently   present    concomitantly.       The 
alopecia  is  not  especially  localized;    it 
affects  uniformly  the  scalp,  thinning  out 
the  hair. 

The  alopecia  of  convalescence  pro- 
gresses rapidly,  being  produced  in  the 
course  of  a  few  weeks.  It  generally 
affects  all  parts  of  the  scalp  equally,  and 
rarely  results  in  complete  baldness. 

Cachectic  alopecia  occurs  in  the  course 
of  pulmonary  phthisis,  cancer,  cirrhosis, 
malaria,  scorbutus,  diabetes,  etc.  It 
affects  the  entire  scalp  impartially.  The 
remaining  hairs  are  dry,  lustreless,  and 


ALOPECIA.     ETIOLOGY. 


235 


brittle,  often  breaking  off  before  falling 
out.  Fournier  (La  M6d.  Mod.,  '90). 
Syphilitic  Alopecia.  —  This  variety  of 
alopecia  is  usually  found  in  irregular 
thinned-out  patches  or  streaks  over  al- 
most all  the  scalp.  The  hairs  are  dry 
and  their  roots  are  atrophied;  they  fall 
out  rapidly.  Every  degree  may  be  ob- 
served, from  simple  thinning  of  the  hair 
to  general  alopecia  of  the  body.  Some 
seborrhcea  of  the  scalp  is  frequently 
present.  The  eyebrows  are  frequently 
thinned. 

In  some  cases  syphilitic  alopecia  is  due 
to  secondary  or  tertiary  lesion  of  the 
scalp. 

Syphilitic  alopecia  occurs  in  the  third 
to  the  sixth  month  of  the  disease,  or, 
rarely,  in  poorly  treated  cases,  at  the 
end  of  one  or  even  two  years.  It  comes 
early  in  the  disease  or  not  at  all. 

There  are  two  forms  of  syphilitic 
alopecia:  the  symptomatic,  accompanied 
either  by  pustulo-crustaceous,  "acnei- 
form"  lesions,  forming  the  little  brown- 
ish or  blackish  crusts  so  common  in  the 
scalp  from  the  third  to  the  sixth  month 
of  syphilis,  or,  more  rarely,  by  a  very 
slight  pityriasis-like  eruption,  sometimes 
only  to  be  distinguished  by  a  lens;  the 
idiopathic,  which  is  the  most  common, 
and  which,  in  reality,  is  accompanied  by 
a  lesion.    (Giovaninni  and  Darier.) 

There  is  a  proliferation  in  the  hair- 
bulb,  and  the  fallen  hair  is  often  found 
to  be  atrophied  at  its  root.  There  is  no 
itching,  redness,  nor  other  symptom  oc- 
curring in  connection  with  syphilitic  alo- 
pecia, other  than  the  mere  falling  of  the 
hair.  It  is  asymmetrical,  affecting  any 
locality  by  chance.  Sometimes  the  fall 
of  hair  is  diffused,  resulting  in  a  general 
thinning;  at  other  times  it  occurs  in 
patches;  occasionally  both  forms  occur 
together.  Fournier  (L'Union  Med.,  Dec. 
4,  '90). 

Premature  Idiopathic  Alopecia.— This 
form  of  alopecia  may  begin  early.     The 


falling  hairs  are  replaced  by  smaller 
hairs,  which  in  their  turn  fall  out,  until 
finally  only  a  smooth,  shining  scalp  is 
left. 

Frequently,  besides  the  fringe  of  hair 
always  left  at  the  back  of  the  head  a 
small  tuft  of  hair  is  left  at  the  anterior 
portion  of  the  scalp,  just  above  the 
middle  of  the  forehead.    (Jackson.) 

Two  cases  of  alopecia  universalis  ob- 
served in  male  adults  presenting  the 
sequelae  of  iridochoroiditis.  In  one  case 
the  ocular  disease  appeared  subsequent 
to  the  loss  of  hair;  in  the  other  it  pre- 
ceded it  by  about  a  year.  Froelich  (Re- 
vue Med.  de  la  Suisse  Rom.,  Dec.,  '90). 

Case  of  complete  generalized  alopecia 
combined  with  partial  anaesthesia  and 
analgesia  in  a  man  20  years  old.  Bissett 
(Maritime  Med.  News,  Feb.,  '94). 

Etiology.  —  Alopecia  following  acute 
and  chronic  general  diseases  is  due  to  le- 
sions of  the  hair  caused  by  the  disease, 
aided  by  neglect  of  the  hair  during  ill- 
ness. It  occurs  most  frequently  after 
typhoid  fever,  the  eruptive  fevers,  espe- 
cially scarlatina,  and,  less  frequently, 
erysipelas.  The  severer  phlegmonous 
diseases  and  typhus  are  followed  by  alo- 
pecia, as  also  occasionally  severe  acci- 
dents, hffimorrhages,  and  pregnancy. 
Many  women  lose  their  hair  after  a 
perfectly  normal  labor.     (Fournier.) 

All  prolonged  debilitating  influences; 
excessive  work,  intellectual  labor  espe- 
cially; genital  excesses,  overindulgence 
at  the  table,  watching,  and  late  hours 
may  give  rise  to  alopecia.  Excessive 
intellectual  work,  however,  is  less  likely 
to  produce  alopecia  than  the  other  forms 
of  excess. 

As  regards  premature  idiopathic  alo- 
pecia, women  are  less  frequently  affected 
than  men.  In  many  cases  this  form  of 
alopecia  seems  to  be  hereditary. 

Study  of  300  cases.  Conclusion  that 
baldness  is  more  common  in  men  than  in 


236 


ALOPECIA.    PATHOLOGY. 


women.  It  seems  to  be  more  common  in 
unmarried  men.  Most  patients  are  found 
to  lead  in-door  lives,  and  belong  to  the 
intellectual  class.  Usually  the  loss  of 
hair  begins  before  the  thirtieth  year. 
In  women  it  usually  constitutes  a  gen- 
eral thinning;  in  men  it  affects  the  top 
of  the  head.  Dandruff  is  usually  a  factor 
in  the  causation;  heredity  is  also  active. 
When  complicating  diseases  are  present, 
they  are  usually  those  that  affect  the 
general  nutrition.  G.  T.  Jackson  (Med. 
Record,  May  26,  1900). 
Excessive  mental  work,  excesses,  and 
a  bad  hygiene  of  the  scalp  seem  to  be 
factors  in  its  development.     (Brocq.) 

Pressure  of  the  anterior  temporal,  pos- 
terior temporal,  and  occipital  arteries  by 
a  stiff  hat  has  been  mentioned  as  a  cause 
of  this  form  of  baldness.  (F.  A.  King.) 
The  escape  of  the  little  tuft  of  hair 
above  the  forehead  has  been  attributed 
to  the  fact  that  the  supra-orbital  arteries 
escape  from  pressure  by  their  passage 
between  the  two  frontal  eminences. 
(Jackson.) 

The  blood-supply  to  the  scalp  is  con- 
veyed by  the  frontal,  temporal,  and 
occipital  arteries,  situated  just  where  a 
tight  hat  would  press  on  them  and  bring 
about  a  gradual  starvation  of  the  hair- 
follicles.  A  woman,  on  the  other  hand, 
wears  her  hat  resting  lightly  on  top  of 
the  head,  bringing  no  pressure  whatever 
on  the  arteries,  and  thus  escapes  bald- 
ness. The  maximum  of  hat-pressure  in 
a  man  comes  on  the  frontal  arteries,  and 
in  consequence  we  find  baldness  gener- 
ally commences  on  the  regions  supplied 
by  those  vessels.  M.  C.  Black  (Indian 
Lancet,  Apr.  16,  '98). 

Alopecia  is  a  symptom  resulting  from 

many  different  sources  of  irritation  of 

peripheral  nerves.     The  commonest  and 

therefore  the  most  important  of  these 

causes  is  dental  irritation,  as  shown  in 

three  hundred  consecutive   cases.     Jae- 

quet    (Annales   de   Derm,   et   de    Syph., 

Feb.  and  March,   1902). 

That  frequent  washing   of  the   head 

encourages  loss  of  hair  is  the  opinion  of 

the  majority  of  dermatologists. 


Pathology.  —  In  alopecia  following 
acute  and  chronic  general  diseases  the 
hairs  are  no  longer  formed;  their  roots 
become  atrophied,  and  they  finally  fall 
out.  The  alopecia  of  convalescence  is 
due  to  disturbance  of  nutrition  of  the 
tissues. 

Premature  idiopathic  alopecia  is  due 
to  a  fibrous  transformation  of  the  derma, 
which  strangles  in  its  meshes  the  ele- 
ments found  in  the  scalp,  especially  the 
hair-follicles.  As  to  the  pathogenesis, 
alopecia  may  be  considered  a  specific 
microbie  affection. 

The  specific  microbacillus  of  fatty 
seborrhcea,  when  introduced  into  the 
pilosebaceous  follicle,  produces  four 
constant  results:  (a)  sebaceous  hyperse- 
cretion; (b)  sebaceous  hypertrophy;  (c) 
progressive  papillary  atrophy;  (d)  death 
of  the  hair.  These  phenomena  result 
from  seborrhoeic  infection  vipon  smooth 
regions  as  well  as  upon  the  hairy  ones. 
The  vertex  is  the  seat  of  election  of  this 
infection.  Common  baldness  is  only  a 
chronic  fatty  seborrhcea  of  the  vertex. 
Not  only  is  follicular  seborrhoeic  infec- 
tion indispensable  in  the  production  of 
baldness,  but  this  seborrhoeic  infection 
remains  intense,  pure,  and  permanent 
until  the  baldness  is  fully  and  perma- 
nently established.    (Sabouraud.) 

Seborrhcea  oleosa  is  due  to  a  micro- 
bacillus  which  had  already  been  dis- 
covered, but  not  rightly  interpreted  by 
Unna.  This  microbacillus  forms  a  mass 
in  the  upper  third  of  the  hair-follicle, 
between  the  surface  of  the  skin  and  the 
point  where  the  sebaceous  gland  opens 
into  the  follicle.  This  mass  is  the  oily 
cylinder  which  may  be  extracted  from 
the  follicle  by  pressure  on  the  skin. 
Secondary  infections  may  be  superadded 
to  seborrhcea  of  the  face,  giving  rise  to 
acne  or  furunculosis.  On  the  scalp  it 
causes  seborrhosic  alopecia. 

Ordinary  alopecia  areata  is  closely  re- 
lated to  seborrhcea.     Any  patch  of  alo- 


ALOPECIA.    PROGNOSIS.    TREATMENT. 


237 


pecia  areata  is  the  seat  of  an  intense 
localized  seborrhoeic  infection,  both  pre- 
vious to  the  loss  of  hair  and  while  the 
latter  persist. 

In  chronic  alopecia  areata  the  infection 
of  the  hair- follicle  is  a  permanent  one; 
acute  alopecia  areata  is  a  localized  acute 
seborrhoea;  alopecia  decalvans  is  a  gen- 
eral chronic  seborrhoea.  E.  Sabouraud 
(Ann.  de  I'Inst.  Past.,  Feb.,  '97). 

Alopecia   probably   due   to   autoinfec- 
tion,  the  poison — "trichotoxicon'' — being 
absorbed  by  the  blood  from  the  air-ves- 
icles  of   the   lungs.     The   poison  would 
then  be  elaborated  dui'ing  decomposition 
of  organic  matter  normally  present  in 
respired  air.    Parker  (Med.  Record,  July 
13,  1901). 
These  opinions  of  Sabouraud  are  not 
at   present    accepted   by    dermatologists 
generally. 

Prognosis.  —  In  senile  alopecia  the 
prognosis  is  unfavorable,  the  chances  of 
cure  being  practically  nil. 

In  alopecia  following  acute  general 
diseases,  on  the  contrary,  the  prognosis 
is  generally  good,  and  the  hair  soon  re- 
covers its  former  state,  though  in  some 
eases  seborrhoea  persists  and  requires 
careful  treatment  to  prevent  relapse  of 
the  alopecia. 

In  serious  chronic  diseases,  however, 
such  as  phthisis  or  cancer,  the  prognosis 
is  unfavorable. 

The  alopecia  of  convalescence  is  tem- 
porary and  reparable;  entire  repair  of 
the  loss  occurring  in  young  people;  after 
forty  years  of  age  the  hair  is  rarely 
reproduced  in  its  integrity.  Fournier 
(La  Med.  Mod.,  Dec.  11,  '90). 

[By  no  means  is  this  always  the  case 
in  youth  in  my  experience.  A.  Van 
Haklingen,  Assoc.  Ed.,  Annual,  '92.] 

Syphilitic  alopecia,  when  not  due  to 
a  local  lesion,  is  only  temporary  and  is 
soon  recovered  from  by  an  appropriate 
specific  and  hygienic  treatment.  When 
due  to  a  local  lesion  the  alopecia  may 
be  incurable  if  the  hair-follicle  has  been 
destroyed. 


Syphilis  never  causes  permanent  and 
complete  baldness.  Properly  treated,  it 
is  accompanied  by  e.xtensive  alopecia  in 
only  one  case  in  twenty.  Fournier 
(L'Union  M6d.,  Dee.  4,  '90). 

Premature  idiopathic  alopecia  is  usu- 
ally looked  upon  as  beyond  treatment. 

Treatment.  —  Premature  Idiopathic, 
Senile,  and  Congenital  Alopecia.  —  In 
these  varieties  general  treatment  is  of 
importance.  Arsenic  and  iron,  continued 
for  a  long  time  and  in  small  doses,  alter- 
nately, should  precede  all  the  methods 
resorted  to.    (E.  Besnier.) 

A  tonic  treatment  should  be  given 
where  the  nervous  system  seems  to  be 
at  fault.  The  following  pill  should  be 
taken  thrice  daily:  — 

ij  Strychnine  sulphate,  Vao  grain. 
Reduced  iron. 
Quinine  bisulphate,  of  each,  1  grain. 

For  one  capsule. 

When  starvation  of  the  nerves  seems 
to  be  present,  the  compound  syrup  of  the 
hypophosphites  (Fellows's)  is  ordered  in 
1-drachm  doses,  thrice  daily,  with  Vso 
grain  sulphate  of  strychnia  in  each  dose. 
Doses  of  '/s  to  Vb  grain  of  muriate  of 
pilocarpine  in  a  powder,  daily,  at  bed- 
time, in  water,  are  also  of  use.  Ohmann- 
Dumesnil  (New  Orleans  Med.  and  Surg. 
Jour.,  Juty,  92). 

Mercuric  bichloride  or  calomel  inter- 
nally, alternately  with  tincture  of  ignatia 
amara,  30  drops  daily  in  three  doses,  or 
sulphurous  acid,  internally,  are  also  rec- 
ommended.    (Shoemaker.) 

Excesses  of  any  nature  should  be  re- 
frained from,  and  any  habit  or  occupa- 
tion tending  to  depress  the  general  vital 
process  be  counteracted. 

Alopecia  should  be  treated  not  onlj'  by 
local  application,  but  by  remedies  which 
influence  the  entire  system.  Strong  sul- 
phur-baths of  thirty  to  forty  minutes, 
followed  by  massage  for  ten  or  twenty 
minutes  and  hot  spray  for  three  to  five 
minutes,  are  useful.  A  half-pint  of 
sulphur-water  should  be  taken  morning 


238 


ALOPECIA.    TREATMENT. 


and  evening,  while  iodine  tincture  and 
hot  sulphur-water  should  be  sprayed 
over  the  scalp.  Ferras  (Annales  de  Derm, 
et  de  Syph.,  vol.  iv,  No.  10,  '94). 

Eesorcin  is  of  great  serTice  in  the 
treatment  of  alopecia.    (Bulkley.) 

Broeq  recommends  the  following 
methods  of  using  this  remedy: — 

Ix  Eesorcin,  1  V2  grains. 

Hydrochlorate  of  quinine,  3  grains. 

Pure  vaselin,  1  ounce. 
This  is  to  be  appHed  to  that  part  of 
the  scalp  which  is  devoid  of  hair  or  from 
which  the  hair  is  rapidly  falling.  If  the 
falling  of  the  hair  persists  it  is  well  to 
incorporate  with  it  5  to  15  minims  of 
the  tincture  of  cantharides,  or  to  use  the 
following: — 

]^   Eesorcin,  3  grains. 

Hydrochlorate  of  quinine,  5  grains. 
Precipitated  sulphur,  30  grains. 
Pure  vaselin,  1  oimce. 

Should  these  preparations  produce 
much  irritation  of  the  scalp,  an  oint- 
ment composed  of  20  grains  of  borax  to 
100  of  vaselin  should  be  applied.  After 
the  irritation  is  relieved,  weaker  prepa- 
rations of  resorcin  and  quinine  can  be 
employed,  of  which  the  following  is  an 
example: — 

]^   Salicylic  acid,  5  grains. 
Eesorcin,  3  grains. 
Hydrochlorate  of  quinine,  5  grains. 
Precipitated  sulphur,  30  grains. 
Pure  vaselin,  1  ounce. 

Should  the  falling  of  the  hair  be  as- 
sociated with  seborrhoeic  eczema,  a  mer- 
curial ointment,  sitch  as  that  of  yellow 
oxide  of  mercury,  varying  in  strength 
from  1  in  25  to  1  in  10,  according  to  the 
severity  of  the  trouble,  shoitld  be  used. 
This  is  only  to  be  rubbed  upon  isolated 
patches  at  a  time.  After  it  has  been 
employed  and  an  alterative  effect  upon 


the  skin  produced,  resorcin  may  again 
be  resorted  to: — 

I^   Eesorcin,  4  grains. 
Salicylic  acid,  7  grains. 
Pure  vaselin,  1  ounce. 
When  the  scalp  is  excessively  greasy 
the  ointment  previously  employed  and 
the  natural  oil  of  the  skin  should  be 
removed  by  washing  the  scalp  with  a 
weak  solution  of  ammonium  acetate  or 
by  using  Castile  soap  and  warm  water. 
Under  no  circumstances  should  the  oily 
preparations  be  used  continuously  with- 
out  occasional   cleansing   of  the  scalp. 
(Brocq.) 

For  seborrhoea  of  scalp  with  beginning 
alopecia    foUow'ing  procedure   should  be 
carried  oiit  daily  or  once  or  twice  weekly 
according   to   the   severity   of   the   case. 
1.  Wash  scalp  with  tar-soap  for  ten  min- 
utes.    2.  After  rinsing,  wash  scalp  with 
V:-per-cent.   solution   of   corrosive   subli- 
mate in  hot  water.     3.  Dry  scalp,  and 
rub  into  it  a  5-per-cent.  naphthol  pomade, 
removing  any  excess  of  the  same.    Bayet 
(Med.  News,  May  21,  '98). 
The  following  lotion  sometimes  proves 
beneficial  at  the  beginning  of  the  afEec- 
tion: — 

I^  Acetic  acid,  ^/^  ounce. 

Pulverized  borax,  1  drachm. 
Glycerin,  3  drachms. 
Alcohol  at  60°,  y,  ounce. 
Eose-water,  V„  pint. 

Another  procedure  that  proves  oc- 
casionally effective  is  to  rub  the  scalp 
lightly  twice  or  thrice  weekly,  for  three 
or  five  minutes,  with  a  soft  brush  or 
sponge  dipped  in 

I^  Sodium  bicarbonate,  1  drachm. 
Distilled  water,  5  ounces. 

A  small  amount  of  oil  is  to  be  put 
upon  the  hair  the  first  or  second  day 
following  each  of  the  above  applications. 
(Pincus.) 

The  head  may  be  washed  with  the 


ALOPECIA.    TREATMENT. 


239 


yelks  of  eggs,  or  white  almond-oil  soap 
or  with  tar-naphthol  or  ichthyol  soap, 
according  to  the  degree  of  tolerance  of 
the  scalp. 

Any   alcoholic   preparation   to   which 
has  been  added  a  small  amount  of  tinct- 
ure   of    cantharides,    tincture    of    nux 
vomica,   acetic   acid,    salicylic   acid,    or 
citric  acid,  from  ^/o  to  5  per  cent.,  is 
recommended   by   Besnier   and   Doyon. 
It  is  applied  with  a  piece  of  absorbent 
cotton  after  carefully  drying  the  scalp. 
The  tinctura  saponis  viridis,  often  used 
to  shampoo  the  scalp,  is  sometimes  too 
strong.    An  ordinary  soda-soap,  made  by 
dissolving  about   1   ounce   in   1   pint   of 
water,  and  adding  some  soda  or  potassa, 
may  be  used  instead.     When  the  scalp 
is  cleansed,  1  part  of  benzol   (from  coal- 
tar),  mixed  with  10  parts  of  alcohol,  is 
to  be  applied. 

If  this  fails  a   1-  to   3-per-cent.   alco- 
holic solution  of  naphthol,  or  the  follow- 
ing formula  may  be  used:  — 
B  Eesorcin,  5  parts. 
Alcohol,  150  parts. 
Castor-oil,  2  parts. 
Other  formulae  of  value  are: — 
R  Quinine  sulphate,  1  part. 
Alcohol,  60  parts. 
Cologne-water,  1  part. 
Either  of  these  may  be  applied  locall}', 
after  carefully  washing  the  scalp. 

After  cutting  the  hair  short  and  wash- 
ing with  soap  the  following  lotion  is 
applied.  Perchloride  of  mercury,  '/^ 
part;  acetic  acid,  1  part;  alcohol,  100 
parts;  ether  and  alcoholic  solution  of 
lavender,  of  each,  50  parts.  After  dry- 
ing the  head  is  rubbed  with  lactic  acid, 
about  30  per  cent.  Balzer  (Jour,  des 
Pratic,  Aug.  24,  1901). 

Alopecia  Followinig  Acute  and  Chronic 
General  Diseases.  —  Any  general  treat- 
ment appropriate  to  the  primary  disease 
naturally  tends  to  improve  the  local 
process.  A  tonic  treatment  further 
assists  the  curative  efforts. 

After  careful  brushing  out  of  the  hair 
the  head  should  be  washed  with  a  decoc- 


tion of  saponaria,  or  three  yelks  of  eggs 
beaten  up  with  one  part  of  lime-water, 
or  with  warm  water  and  good  soap,  and 
then  carefully  dried.  This  should  be 
followed  by  the  following  lotion  rubbed 
in  daily: — 

I^   Alcohol  at  80°,  2  V2  ounces. 
Camphorated  alcohol, 
Eum, 

Tincture  of  cantharides. 
Glycerin,  of  each,  75  minims. 
Santal-wood  essence, 
Wintergreen-essence,    of    each,    5 

minims. 
Pilocarpine     hydrochlorate,     7  ^/j 

grains. 

This  is  to  be  rubbed  in  lightly  once 
daily. 

Any  exciting  application  containing 
rum  or  camphorated  alcohol  with  spirit 
of  rosemary — and  to  which  may  be  added 
quinine,  in  the  proportion  of  4  to  30  of 
either  tincture  of  nux  vomica,  tincture 
of  capsicum,  or  tincture  of  cantharides — 
may  be  employed. 

If  the  hair  be  very  dry  some  almond- 
oil  or  castor-oil  may  be  applied  from  time 
to  time. 

Prevention  through  massage-exercise 
is  nine  points  in  the  law  of  treatment 
of  baldness.  This  should  be  begun  in 
early  life,  at  the  time  when  the  youth 
is  developing  into  the  more  sober  man, 
when  his  occipito-frontalis  muscle  has 
become  more  and  more  subordinated  to 
his  will.  Massage  should  be  performed 
the  same  way  as  in  other  regions,  first 
freeing  the  vessels  farthest  from  the 
seat  of  trouble,  and  gradually  approach- 
ing the  centre.  It  should  be  done  at 
night  as  well  as  in  the  morning,  par- 
ticularly at  night,  as  gravity  has  little, 
or  comparatively  little,  chance  through 
the  day.  If  the  scalps  of  men  received 
enough  exercise  as  the  scalps  of  women, 
there  should  be  on  the  vaults  of  their 
craniums  a  luxuriant  tonsure.  George 
Elliott  (Dominion  Med.  Monthly,  March, 
1902). 


240 


ALOPECIA. 


ALOPECIA  AREATA. 


It  is  well  to  keep  the  hair  cut  short 
until  it  begins  to  grow  again. 

Universal  alopecia  arrested  in  a  case 
by  thyroid  extract,  5-grain  tabloids  three 
times  a  day.  H.  R.  Beevor  (Brit.  Med. 
Jour.,  July  13,  '95). 

[I  cannot  too  strongly  warn  the  reader 
against  placing  too  great  confidence  in 
the  marvelous  results  obtained  recently 
in  numerous  dermatoses  from  the  thy- 
roid treatment.  The  subject  requires 
considerable  control  study  before  these 
results  can  be  accepted.  L.  Bkocq, 
Assoc.  Ed.,  Annual,  '96.] 

The  influence  of  thyroid  extract  shown 
in  the  case  of  a  woman,  aged  66  years, 
suffering  from  myxoedema,  in  whom  the 


2.  Wash  the  scalp  with  soap  and  warm 
water  every  morning. 

3.  Apply  the  following  ointment: — 

]^   Salicylic  acid,  75  grains. 

Precipitated  sulphur,  2'/,  drachms. 
Lanolin, 

Vaselin,   of  each,   1  ounce  and  6 
drachms. 

Every  evening  rub  in  with  a  soft  brush 
the  following  lotion: — 

]^  Spirit  of  rosemary,  3  ^/j  ounces. 
Cantharides  tincture,  2  ^/j  drachms, 
or  salicylic  acid,  15  grains. 


Influence  of  thyroid  extract  upon  hair-growth  and  geneial  appeal ance  m  mvxoedema. 
The  same  patient,  a  woman  aged  66,  as  she  appeared  before  treatment  and  as  she 
appeared  after  taking  two  thyroid  tabloids  daily  for  fifteen  months.      (T.  F.  Raven.) 


growth    of   hair    during    fifteen    months 
was  striking  (see  wood-cuts).     Does  not 
the  remarkable  influence  of  thyroid  ex- 
tract upon  hair-growth  suggest  that  the 
thyroid  gland  in  its  function  is  largely 
occupied    with    nutrition    of    the    skin? 
Thomas  F.  Raven  (Brit.  Med.  Jour.,  July 
31,  '97). 
Syphilitic  Alopecia.  —  The  best  treat- 
ment consists  in  early  and  thorough  anti- 
syphilitic  measures.    Local  treatment  is 
not    really    necessary,    but,    if    applied, 
should  consist  in  lotions  containing  mer- 
curic perchloride,  1  to  500  or  1  to  1000, 
or   ointments   containing   either  yellow 
oxide  or  sulphate  of  mercury.     (Broeq.) 
The    following    treatment    is    recom- 
mended by  E.  Besnier: — 
1.  Cut  the  hair  short. 


Syphilitic  alopecia  is  easily  curable  by 
the  internal  use  of  mercury.  Local  appli- 
cations are  useless.  Fournier  (L'Union 
Med.,  Dec.  4,  '90). 

[Here  I  must  differ  from  Fournier; 
local  applications  are  valuable  adjuvants. 
A.  Van  Haklingen,  Assoc.  Ed.,  Annual, 
'92.] 

George  H.  Rohe, 

Baltimore. 

ALOPECIA  AREATA. 

Definition.  —  A  disease  of  the  hair 
characterized  by  the  rapid  development 
of  more  or  less  circular  or  oval  bald 
patches  on  the  scalp  and  sometimes  in 
other  parts  of  the  body. 

Symptoms.  —  Alopecia  areata  usually 
presents  itself  in  the  form  of  rounded 


ALOPECIA  AEEATA.     DIAGNOSIS. 


241 


or  oval  patches,  situated  on  the  scalp 
or  other  hairy  regions  of  the  body.  The 
skin  of  these  patches  is  white  and  smooth, 
and  in  some  cases  discolored  and  some- 
what depressed.  At  times  the  afEeetion 
extends  over  the  entire  cutaneous  surface. 

The  hairs  become  dry  and  colorless, 
their  roots  are  atrophied,  and  they  rap- 
idly fall  out. 

Three  main  forms  of  alopecia  areata 
have  been  recognized:  alopecia  areata 
archromatica  (Bazin),  in  which  the  bald 
patches  are  discolored  and  excavated,  as 
described  above;  false  alopecia  areata,  in 
which  the  patches  of  baldness  are  more 
or  less  covered  with  thin,  brittle  hairs, 
which  can  easily  be  pulled  out  along 
with  their  roots:  a  form  of  ringworm. 
The  third  variety  is  alopecia  areata  de- 
calvans,  in  which  the  entire  scalp,  or  the 
skin  of  other  parts  of  the  body,  becomes 
bald  in  a  few  days,  the  hair  falling  with 
great  rapidity. 

In  alopecia  areata  the  hairs  are  dry, 
lustreless,  thin,  and  brittle.  Their  roots 
are  either  atrophied  and  thread-like  or 
swollen  into  irregular  nodules.  The 
medulla  has  disappeared,  and  air-bubbles 
may  be  seen  in  their  interior.  They  fre- 
quently break  close  to  the  scalp,  their 
free  extremity  being  brush-like  in  ap- 
pearance. 

In  the  so-called  false  alopecia  areata 
the  few  hairs  left  retain  their  hue  and 
consistency. 

Deductions  based  on  a  study  of  257 
cases:  — 

Four  classes  of  cases  are  included 
under  the  generic  name  alopecia  areata: 

1.  Universal  alopecia;    it  is  very  rare. 

2.  Baldness  occurring  in  one  or  more 
patches  at  the  site  of  an  injury  or  in 
the  course  of  a  recognizable  nerve.  This 
is  comparatively  infrequent. 

3.  A  form  first  described  by  Neumann 
as  "alopecia  circumscripta  seu  orbicu- 
laris." The  patches  are  small,  from 
lentil-  to  pea-  size,  much  depressed  below 


the  surface,  with  often  a  marked  de- 
crease of  the  sensibility.  The  prognosis 
is  unfavorable. 

The  first  three  classes  form  less  than 
10  per  cent,  of  all  the  cases  classed  as 
alopecia  areata.  They  are  undoubtedly 
of  trophoneurotic  origin. 

4.  The  largest,  numerically,  is  due  to 
a  vegetable  parasite.  Crocker  (Lancet, 
Feb.  28,  Mar.  7,  '91). 

Two  cases  in  which  the  nails  were  af- 
fected in  patients  suffering  from  alopecia 
areata  of  the  scalp.  One  was  a  delicate 
nervous  young  woman.  The  nails  became 
affected  some  months  after  alopecia  had 
manifested  itself  on  her  scalp.  The  sec- 
ond case  was  that  of  a  young  man  who 
had  a  typical  patch  of  alopecia  areata 
on  the  scalp.  The  nails  in  both  cases 
presented  a  discolored  granite-like  ap- 
pearance due  to  minute  punctiform 
depressions,  which  gave  them  a  dirty, 
unpolished  look.  C.  Audry  (Jour,  des 
Malad.  Cutan.  et  Syph.,  Mar.,  1900). 

Diagnosis. — Alopecia  areata  should  be 
distinguished  from  syphilitic  alopecia; 
biTt  usually  in  this  latter  affection  the 
patches  are  merely  thinned  out  and 
arranged  irregularly  over  the  head  in 
streaks;  other  symptoms  of  syphilis  are 
frequently  present. 

The  alopecia  in  patches  resembles,  in 
a  certain  way,  alopecia  areata,  but  it  has 
certain  characters  which  are  perfectly 
pathognomonic.  Alopecia  areata  makes 
a  clean  sweep,  all  the  hairs  on  the  patch 
falling  out.  In  syphilis,  however,  some 
hairs  always  remain  on  the  affected 
patches,  which  also  are  never  so  regular, 
rounded,  or  extensive  as  those  of  alopecia 
areata.  Another  diagnostic  point  is  that 
the  area-like  alopecia  of  syphilis  is  al- 
ways accompanied  by  the  disseminate 
form,  whereas  in  alopecia  areata  the 
hair  is  usually  normal  up  to  the  very 
edge  of  the  bald  spot.  Finally,  alopecia 
areata  decolorizes  the  skin,  which  be- 
comes dead-white,  while  the  bald  areas 
of  syphilis  retain  their  natural  color. 
Fournier   (L'Union  M6d.,  Dec.  4,  '90). 

Premature  Idiopathic  Alopecia. — From 
ordinary  alopecia,  alopecia  areata  should 
16 


343 


ALOPECIA  AREATA.    ETIOLOGY. 


be  recognized  by  its  white,  smooth  ap- 
pearance and  rounded,  limited  form. 

Heredity  plays   a   small   part  in  pro- 
ducing early  alopecia.     Only  four  incon- 
testable   instances    were   found    in    over 
three   hundred   cases   treated.      Over   90 
per   cent,    are   due   to   the   one   disease: 
eczema  seborrhoeicum.     Two  varieties  of 
diploeocci  isolated,  both  of  which  inoc- 
ulated  upon   healthy   subjects   produced 
lesions  characteristic  of  the  disease.    One 
was  a  non-chromogenic  organism  which 
produced  pityriasic  manifestations;    the 
other,  chromogenic,  produced  lesions  cov- 
ered with  yellowish,  greasy  scales.    Both 
together  cause  greasy,  crumbling  scales. 
Elliot   (Amer.  Derm.  Assoc,  Sept.  17  to 
19,  '95). 
Trichophytosis. — Microscopical  exami- 
nation in  this  disease  shows  at  once  that 
no  distinct  parasite  is  found  in  alopecia 
areata,  while  in  trichophytosis  the  hair 
is  filled  with  spores.     The  hairs,  when 
seized    with    forceps,    become    crushed, 
while    they    do    not   yield    in    alopecia 
areata. 

Case  of  a  boy  presenting  a   perfectly 
bald  spot  about  two  inches  in  diameter 
on  the  top  of  the  head,  with  the  typical 
features  and  hair  of  alopecia  areata.     It 
had  begun,  however,  as   a  scaly  patch. 
Miscroscopical  examination  showing  the 
presence  of  spores,  it  was  pronounced  to 
be    trichophyton    by    Bulkley.      White- 
house  (Jour.  Cut.  and  Genito-Urin.  Dis., 
Oct.,  '93). 
Etiology.  • —  In  the  great  majority  of 
cases  alopecia  areata  occurs  as  a  result 
of  contagion.    This  has  been  fully  dem- 
onstrated clinically  and  experimentally. 
The  implements  of  the  hair-dresser  are 
almost  the  only  agents  of  transmission  of 
contagion,  doubtless  because  they  alone 
can   cause   the   abrasions  necessary   for 
sowing  the   organism   with  which   con- 
tamination occurs.     This  explains  why 
alopecia  areata  seems,  at  iirst  sight,  to 
be  a  sporadic  affection  in  cities,  and  why 
in   solleges  and  barracks  it   may  take 
the  shape  of  an  epidemic.    Every  disease 


propagated  from  one  individual  to  an- 
other supposes  an  active  cause  capable 
of  multiplication  and  reproduction:  that 
is  to  say,  a  living  pathogenic  parasite. 

There  is  a  close  relationship  between 
tinea  tonsurans  and  alopecia  areata. 
Cases  with  all  the  signs  of  alopecia 
areata  may  arise,  not  in  children  only, 
but  in  adults,  from  contact  with  ordi- 
nary tinea  tonsurans.  It  is  not  the  bald 
form  of  tinea  tonsurans,  because  the 
short  hairs,  as  in  alopecia  areata,  are 
club-shaped,  whereas,  in  tinea  tonsurans,, 
they  are  bent  and  twisted.  Crocker 
(Lancet,  Feb.  28,  Mar.  7,  '91). 

Ringworm  and  alopecia  areata  are  in 
many  ways  connected.  Of  137  oases  of 
the  latter  seen  by  the  author,  32  per  cent, 
gave  a  history  of  ringworm,  either  per- 
sonal or  occurring  in  some  member  of  the 
household.  P.  Abrahams  (Med.  Press 
and  Circular,  Nov.  22,  '93). 

Eight  boys,  all  between  the  ages  of 
12  and  13,  belonging  to  the  same  gym- 
nasium— six  in  one  class  and  two  in  an- 
other— were  within  a  very  short  time 
attacked  with  a  most  typical  alopecia 
areata:  the  hair  fell  out,  while  the  skin 
remained  perfectly  smooth  without  the 
formation  of  any  crusts  or  scabs.  All 
the  six  pupils  were  sitting  near  one  an- 
other on  the  same  bench.  This  epidemic 
proves  the  contagiousness  of  alopecia 
areata  beyond  any  question.  Kober 
(Berliner  klin.  Woch.,  No.   15,  '98). 

Conviction  expressed  that  alopeciar 
areata  is  contagious  under  certain  cir- 
cumstances. Lassar  (Phila.  Med.  Jour., 
Apr.  16,  '98). 

Two  epidemics  of  alopecia  areata  in  an 
Institution  for  homeless  girls  between 
the  ages  of  3  and  14  years.  The  first 
case  occurred  in  a  girl,  11  years  old,  who,, 
when  first  seen,  presented  three  round, 
bald  patches  upon  the  crown  of  the  head, 
clinically  typical  of  alopecia  areata. 
Several  weeks  later  another  girl  was- 
found  to  have  a  bald  patch  upon  the 
crown,  which  increased  rapidly  in  size 
for  a  time.  Four  months  after  the  dis- 
covery of  the  first  case  a  large  number 
of  the  girls  in  the  asylum  were  suddenly 
found  to  be  affected.  After  cutting  the 
hair  of  all  the  children  it  was  found  that 


ALOPECIA  AREATA.    PATHOLOGY. 


243 


63  of  the  69  girls  had  bald  areas  upon 
the  scalp.  One  girl,  who  had  just  entered 
the  institution,  acquired  a  patch  in  three 
days.  After  two  months  the  disease  ap- 
peared to  come  to  a  stand-still;  at  the 
end  of  six  months  almost  all  the  bald 
patches  were  covered  with  hair.  No 
trace  of  micro-organism  was  found.  No 
adult  inmate  of  the  asylum  was  attacked. 
Bowen  (Jour.  Cutan.  and  Genito-Urin. 
Dis.,  Sept.,  '99). 

Alopecia  areata  maj'  also  be  caused  by 
shock,  worn',  overwork,  traumatisms,  or 
epileptic  paroxysms. 

Case  following  prostration  through 
shock,  continued  until  there  was  com- 
plete denudations  of  hairy  portions  of 
the  body.  Morton  (Brooklyn  Med.  Jour., 
Sept.,  '95). 

Two  instances  of  alopecia  areata  oc- 
curring in  epileptics  after  paroxysms,  in 
which  the  neurotic  rather  than  the  para- 
sitic origin  seems  the  more  probable. 
The  hairs  finally  recovered  their  thick- 
ness, volume,  and  color.  In  both  cases 
alike  the  evolution  of  the  lesions  was 
not  interfered  with  by  any  medical  in- 
tervention, either  general  or  local.  F6r6 
(La  Nouv.  Iconog.  de  la  Salpetriere,  '95). 

The  neurotic  theory  of  the  origin  of 
alopecia  areata  is  still  held  by  many  der- 
matologists. 

Prolonged  exposure  to  the  vacuum- 
tube  of  an  x-ray  apparatus  may  give  rise 
to  localized  falling  of  hair. 

Case  of  dermatitis  and  alopecia  after 
the  use  of  the  Roentgen  rays  in  a  young 
man,  aged  17,  in  whom  experiments 
were  carried  out  during  four  weeks,  once 
or  twice  each  day.  The  dermatitis  re- 
sembled that  caused  by  bums.  An 
improvement  soon  occurred.  Marcuse 
(Deutsche  med.  Woch.,  July  23,  '96). 

Case  of  alopecia  areata  as  a  result  of 
exposure  to  the  Roentgen  rays  during 
forty  minutes,  using  a  Thompson  double- 
focus  or  standard  vacuum-tube.  The  dis- 
tance between  the  tube  and  skull  was  a 
little  over  eighteen  inches.  A  large  area 
of  hair  missing  upon  that  side  of  the 
head   exposed  to  the   vacuum-tube;     no 


premonitory  symptoms  of  itching  or  in- 
flammation; the  hair  had  suddenly  fallen 
out  three  weeks  after  the  exposure. 

The  integument  appeared  bald  and 
somewhat  elevated,  and  slightly  oedem- 
atous;  no  redness;  sensibility  not  im- 
paired; no  scaling.  Under  stimulating 
and  hygienic  treatment  downy  hairs  are 
beginning  to  show  themselves.  F.  S. 
Kolle  (Buffalo  Med.  and  Surg.  Jour., 
Dec,  '96). 

True  alopecia  areata  seems  to  occur  in 
syphilitic  subjects  more  frequently  than 
in  other  persons. 

Areas  of  absolute  alopecia  which  occur 
in  the  scalp  or  beaid  in  syphilis  may  be 
small  and  few,  well  circumscribed,  last- 
ing a  short  time,  but  recurring  often. 
This  is  very  different  from  that  general 
thinning  of  the  hair  seen  early  in  the 
disease,  which  never  returns.  A  Foumier 
(Jour,  des  Pratieiens,  Jan.  19,  1901). 

The  percentage  of  alopecia  areata  in 
various  countries  is  approximately  as 
follows:  France,  3  per  cent.;  England, 
2;  Scotland,  1.5;  Vienna,  0.75;  North 
Germany,  0.75  to  1;  America,  0.5. 
(Crocker.) 

In  LillCj  of  5000  cases  of  skin  disease, 
149  cases  were  alopecia  areata;  in  Lyons, 
of  2765  eases,  17;   in  Vienna,  of  5000,  40; 
in   Berlin,   of   1050,  9;     and  in   another 
series    of   3008    cases,   30    were    alopecia 
areata.     In  America,   as  shown   by  the 
statistics  of  the  American  Dermatological 
Association,   alopecia   areata   was   found 
in   794   cases   out  of   123,746   cases.     E. 
Besnier    ("Sur  la  Pelade,"  Travail  lu  a. 
I'Acad.  de  Med.,  July  31,  '88). 
Pathology.  —  The  initial  stage  alone 
of   ordinary   benign   alopecia   areata   is 
microbic.     As   soon   as   the   patch   be- 
comes smooth,  microbes  can  no  longer 
be  found,  neither  in  the  skin  nor  in  the 
follicle.    In  the  beginning  of  the  disease 
almost  all  the  follicles  are  infected  with 
innumerable  microbian  colonies  belong- 
ing to  a  single  bacillary  species  always 
the  same. 

In  benign  cases  the  follicular  infec- 


244 


ALOPECIA  AEEATA.     PATHOLOGY. 


tion  is  transitory;  in  chronic  or  total 
alopecias  the  same  microbe  is  found 
constantly,  with  the  same  localizations. 
The  invariable  presence  of  this  microbe 
wherever  there  is  a  beginning  lesion  gives 
it  a  value  other  than  that  of  an  ordinary 
secondary  infection.  However,  this  mi- 
crnbacillus,  notwithstanding  certain  dif- 
ferences of  form,  cannot  be  distinguished 
with  absolute  certainty  from  the  microbe 
which  Hodara  has  described  as  the  bacil- 
lus of  acne.  If  the  bacillus  of  Hodara 
and  that  of  alopecia  areata  arc  the  same, 
we  must  ascertain  why  in  every  case  of 
alopecia  this  secondary  infection  is  con- 
stant, and  what  role  it  plays.  If  they  are 
different,  they  must  be  differentiated  ex- 
perimentally. Finally,  they  may  be  the 
same  bacilli  which,  under  different  vital 
conditions,  may  or  may  not  secrete  a  toxin 
capable  of  producing  alopecia.    (Broeq.) 

According  to  Sabouraud,  alopecia  and 
alopecia  areata  are  practically  identical. 
The  patch  of  alopecia  areata  is  only  an 
attack  of  acute  circinated  seborrhoea:  in 
other  words,  the  bald  only  become  bald 
by  a  diffused  process  of  chronic  alopecia 
areata.  Alopecia  areata  is  a  contagious 
disease,  the  extension  of  which  is  marked 
by  the  appearance  of  a  special  form  of 
hair:  the  club-shaped  hair.  This  hair 
appears  with  the  disease,  disappears  at 
the  same  time  that  it  ceases  to  extend, 
and  reappears  with  the  renewal  of  ac- 
tivity. Where  the  malady  is  active  it  is 
never  wanting. 

The  microscopical  examination  of  the 
ckib-shaped  hair  shows  that  its  special 
form  is  due  to  a  progressive  atrophy  of 
the  papilla  which  forms  it.  A  histolog- 
ical examination  will  separate  alopecia 

areata    clearly    from    the    cryptogamic 

tineas. 

In  300  cases  examined  by  him,  Sabou- 
raud found  that  all  the  morbid  conditions 
indicate  a  pre-existent  intoxication,  the 


cause  of  which  had  disappeared.  In  the 
earlier  stages,  however,  he  found  that 
one  out  of  every  two  or  three  follicles 
at  the  margin  showed  an  ampuUiform 
dilatation  at  its  upper  part,  which  he 
calls  the  utricle.  {See  colored  plate.) 
This,  when  first  perceptible,  is  roofed  by 
a  dome  having  a  minute  window  in  its 
centre.  In  this  cavity  alone  the  micro- 
organism is  to  be  found.  So  long  as  the 
aperture  remains  closed  the  microbacil- 
lus  exists  in  a  pure  state,  but  when  it 
opens  it  disappears,  and  saprophytic 
fungi  enter.  The  bacillus  is  one  of  the 
smallest  known,  and  is  in  innumerable 
numbers.  It  is,  according  to  him,  con- 
stant in  the  early  stage  of  the  benign 
form.  In  total  alopecia  of  this  type 
there  seems  to  be  two  stages:  in  one  the 
bald  skin  is  oily  and  shining,  and  in  the 
second  it  is  dry  and  rather  scab',  and  in 
which  there  is  a  tendency  to  restoration 
of  hair.  If,  in  the  seborrhoeic  stage,  the 
contents  of  the  follicles  are  expressed  by 
massage,  the  same  organisms  found  in 
the  utricle  are  recognizable  in  immense 
numbers,  less  numerous  in  the  drier 
stage,  and  not  to  be  found  when  healthy 
lanugo  hairs  begin  to  clothe  the  surface. 
Sabouraud  hesitates  to  pronounce  the 
microbe  he  has  discovered  as  the  causal 
element,  for  one  both  identical  in  ap- 
pearance and  in  reaction  to  stains  has 
been  found  habitually  in  the  comedo  and 
in  seborrhoea  of  the  oily  type. 

The  microbes  which  are  found  in  the 
hair  are  diverse;  they  are  habitually  ob- 
served even  upon  scalps  that  are  not 
affected  with  alopecia,  but  only  in  hairs 
which  show  evidence  of  papillary  altera- 
tion anterior  to  the  microbic  invasion. 

Indeed,  none  of  these  microbes,  almost 
all  of  which  have  been  described  by  vari- 
ous authors  as  specific,  can,  according  to 
Sabouraud,  have  any  causal  importance 
in  the  disease. 


FkiJ 


Fir/.  2. 


Alopecia  Areata,  I  Sabouraud  ) 

Frqure  I  Section  of  normal  ham  implanted  portion     Figure  2  Section  of  hair  showing  the  peladic  utricle 


ALOPECIA  AREATA.    PROGNOSIS.    TREATMENT. 


245 


Three  facts  which  militate  in  favor  of 
the  infectious  nature  of  alopecia  areata: 
(1)  the  erythematous  tint  of  recent 
patches;  (2)  tumefaction  of  occipital 
lymph-nodules,  which  often  accompanies 
the  beginning  of  the  disease;  (3)  the  fact 
of  experimental  contagion.  Blaschko 
(Third  Cong,  of  Derm,  and  Syph.,  '97). 

Prognosis. — The  prognosis  of  alopecia 
areata  is  exceedingly  variable;  in  many 
cases  treatment  must  be  continued  for 
years. 

The  more  ancient  the  patch  is,  the 
more  difficult  it  is  to  promote  a  return 
of  the  hair. 

Occipital  or  temporal  alopecia  areata 
recovers  more  slowly  than  that  of  other 
regions  of  the  scalp. 

^Ylien  the  hairs  begin  to  grow  anew 
they  are  frequently  white  at  first,  and 
only  later,  by  the  continuance  of  the 
treatment,  do  they  resume  their  normal 
hue. 

Treatment.  —  The  general  treatment 
usually  recommended  has  for  its  object 
to  strengthen  the  patient.  Increased 
nutrition  and  general  tonics  play  an  im- 
portant part  in  the  methods  indicated. 
Country-air,  physical  exercise,  rest  from 
mental  overwork,  warm  sulphur  shower- 
baths  (Besnier  and  Doyon),  cold  shower- 
baths  on  the  vertebral  column,  iodide 
of  iron,  codliver-oil,  strychnine,  sodium 
arsenate,  the  preparations  of  cinchona, 
and  the  valerianates  have  each  their 
sponsors. 

Food  containing  much  butter,  fat  and 
milk,  phosphates  and  fish,  strychnine, 
and  phosphoric  acid  are  of  service. 

Patients  should  be  well  fed.  The  fats 
and  phosphates  should  be  increased. 
Milk  taken  alone  and  between  meals, 
crushed  wheat,  cream,  and  fish  the  most 
valuable  aliments  for  this  purpose.  The 
best  results  have  been  obtained  under 
the  free  and  continued  administration  of 
strychnine  with  phosphoric  acid.  Arsenic 
should  be  given  alternately  with  the  for- 


mer.   Bulkley  (N.  Y.  Med.  PLCcord,  Mar. 
2,  '89). 

The  progress  of  the  disease  must  be 
arrested  by  shaving  the  hair  around  each 
patch  for  about  half  an  inch  or,  even 
better,  by  shaving  the  entire  head.  Epil- 
ation may  be  done,  instead  of  shaving, 
around  the  bald  patches.    (Brocq.) 

To  effectively  treat  alopecia  areata,  it 
is  necessary  to  act  upon  the  derma,  and 
the  horny  layer  must  first  be  destroyed 
by  the  application  of  a  vesicating  fluid, 
preferably  the  ethereal  solution  of  can- 
tharides.  On  the  following  day  a  15- 
per-cent.  solution  of  nitrate  of  silver 
is  applied  upon  the  denuded  chorium, 
with  or  without  previous  cocaine  anaes- 
thesia. This  may  he  renewed  in  ten  or 
fifteen  days  if  necessary.  The  results 
of  this  treatment  greatly  surpass  in 
effectiveness  those  following  other  pro- 
cedures.   (Sabouraud.) 

The  success  of  epilating  a  ring  of 
hairs  in  the  early  stage  as  a  means  of 
protective  demarkation  against  extension 
is  explained,  if  Sabouraud's  discovery 
should  be  verified. 

In  facial  alopecia  areata  rubbing  of 
the  affected  region  daily  with  tincture  of 
cantharides,  either  pure  or  mixed  with 
spirit  of  rosemary,  according  to  the  irri- 
tability of  the  skin,  is  another  valuable 
measure. 

I>  Tincture  of  cantharides,  1  ounce. 
Spirit  of  rosemary,  3  drachms  to  1 
ounce. 

The  hair  should  be  cut  short.  Van 
Swieten's  solution  rubbed  in,  and  each 
diseased  patch  painted  with  a  thick  coat- 
ing of  1  part  of  iodine  to  30  of  collodion. 
At  the  end  of  a  week  this  film  loosens 
and  begins  to  separate.  Frictions  with 
the  sublimate  solution  are  then  used, 
morning  and  evening,  until  all  the  re- 
maining pellicles  of  collodion  have  been 
removed,  when  a  new  coating  of  iodized 
collodion  is  applied.    After  three  applica- 


246 


ALOPECIA  AREATA.     TREATMENT. 


tions  the  downy,  new  hairs  begin  to 
appear.  Tison  (Jour,  de  M6d.,  Apr.  24, 
'92). 

Antiseptic  preparations  have  been 
recommended  by  a  large  number  of 
authorities. 

In  parasitic  alopecia  areata  (tricho- 
phytosis) the  hair  is  cut  close,  and  a 
solution  of  corrosive  sublimate  (1  to 
750)  or,  preferably, — on  account  of  its 
non-toxic  qualities, — a  3-per-cent.  solu- 
tion of  creolin  is  applied.  This  is  used 
all  over  the  scalp  as  a  p)reventive.  Sapo 
viridis  is  rubbed  into  the  affected  areas, 
and  allowed  to  remain  on  for  five  min- 
utes. After  washing  this  off,  a  small 
quantity  of  the  following  ointment  is 
rubbed  in: — 

I^  Hydrarg.  bichlor.,  1  grain. 

Lanolin,  1  ounce. 
To  be  thoroughly  mixed. 

The  latter  should  be  applied  twice 
daily,  as  a  usual  thing,  but  sometimes  a 
less  frequent  application  suffices. 

In  neurotic  alopecia  areata  the  same 
internal  treatment  is  used  as  in  presenile 
alopecia.  Externally,  in  some  cases, 
cantharidal  collodion  is  applied  to  the 
affected  area,  and,  after  vesication  has 
been  established,  a  dressing  of  some 
bland  ointment.  As  the  collodion  varies 
in  its  effect,  it  is  to  be  applied  at  greater 
or  less  intervals. 

Bulkley's  method,  with  some  modifi- 
cations, is  as  follows:  The  pure  carbolic 
acid  is  applied  twice  a  week,  and  over 
the  entire  area  of  the  patch,  however 
large,  by  freely  swabbing.  Those  por- 
tions which  are  affected  by  the  acid  turn 
milky  white  in  a  few  moments,  and,  if 
they  do  not  do  this,  are  touched  again 
after  awhile.  If  the  parts  that  turn 
white  show  any  very  marked  inflamma- 
tory action,  they  are  passed  over  at  the 
next  sitting.     Generally,  however,  there 


is,  at  most,  but  a  slight  amount  of  des- 
quamation.    (Ohmann-Dumesnil.) 

Case  of  alopecia  areata  of  the  beard 
treated  by  Martin's  method  of  locally 
applied  mercuric-bichloride  solution, 
made  to  penetrate  the  follicles  by  elec- 
tricity. Beall  (Va.  Med.  Monthly,  Feb., 
'91). 

Aflfected  area  covered  with  solution  of 
corrosive  sublimate  in  glycerin,  1  to  100. 
The  scalp  is  then  tattooed  with  a  sharp 
instrument:  an  aseptic  needle,  for  in- 
stance. The  punctures  need  only  be 
slight, — sufficient  to  permit  penetration 
of  the  antiseptic.  Successful  results  in 
most  inveterate  cases.  M.  A.  Martin 
(Gaz.  des  Hop.,  .July  9,  '95). 

Successful  treatment  of  alopecia  areata 
by  means  of  lactic  acid,  applied  gradu- 
ally in  increasing  strengths,  beginning 
with  a  50-per-cent.  solution.  Ristema 
(Brit.  Jour,  of  Derm.,  July,  '98). 

A  50-per-cent.  aqueous  solution  of  lac- 
tic acid  has  a  remarkable  effect  in  alo- 
pecia areata.  As  the  remedy  is  quite 
irritating,  it  should  not  be  used  more 
than  once  a  day.  If  the  pain  should  be 
very  severe  the  acid  is  to  be  suspended 
temporarily  and  anodyne  applications 
used.  In  the  large  majority  of  cases 
cure  was  complete  in  three  months. 
Stojanovitch  (Ann.  de  Dermat.  et  de 
Syph.,  Sept.,  '99). 

The  local  use  of  strong  solutions  of 
carbolic  acid  has  been  advocated  by 
Duhring  and  Bulkley. 

Three  cases  cured  in  five  weeks  by 
painting  the  patches  with  iodized  collo- 
dion, 1  to  30.  It  is  supposed  that  the 
impervious  coating  formed  by  the  collo- 
dion kills  the  micro-organism.  Chatelain 
(Revue  GSn.  de  Clin,  et  de  Th6r.,  Dec. 
31,  '90). 

The  scalp  is  thoroughly  washed  for  ten 
minutes  with  tar-soap,  first  using  hot 
water,  then  cold.  The  parts  having  been 
thoroughly  dried,  a  solution  of  bichloride 
of  mercury.  1  to  900  (equal  parts  of 
water,  glycerin,  and  cologne),  is  rubbed 
in.  The  scalp  is  then  anointed  with  a 
pomade  containing 


ALOPECIA  AREATA.    TREATMENT. 


247 


B  Salicylic  acid,  2  parts. 

Tincture  of  benzoin,  10  parts. 
Neat's-foot  oil,  100  parts. — M. 

This  treatment  should  be  carried  out 
daily  and  continued  for  six  weeks  or 
more.  Lassar  and  Groetzer  (Brit.  Jour, 
of  Derm.,  Feb.,  '91). 

A  95-per-oent.  solution  of  carbolic  acid 
is  applied  to  the  affected  region  and  its 
periphery.  It  is  somewhat  painful  at 
first.  The  skin  whitens,  shrivels,  and 
desquamates.  Two  weeks  later  a  second 
application  may  be  made.  Bulkley 
(Jour.  Cut.  and  Genito-Urin.  Dis.,  Feb., 
'92). 

Tricresol  is  a  very  efficient  remedy  for 
alopecia  areata.  In  nine  cases  an  aver- 
age cure  was  obtained  in  two  and  one- 
half  months.  The  area  should  be  thor- 
oughly cleansed  with  benzin,  and  then 
tricresol  applied  pure  to  the  scalp.  It  is 
well  rubbed  into  the  denuded  patches 
and  into  roots  of  hairs  one-half  inch  be- 
yond each  patch,  by  the  friction  of  a 
small  swab  of  cotton  tightly  wrapped  on 
a  wooden  tooth-pick.  The  burning  and 
pain  soon  pass  away.  These  applications 
are  made  according  to  the  local  effect 
produced,  but  on  the  average  every  five 
to  seven  days  till  desired  result  be  ob- 
tained. Granville  MacGowan  (Pacific 
Med.  Jour.,  Aug.,  '99). 

The  methods  advocated  by  Besnier 
and  Doyon  are  much  employed  on  the 
continent  of  Europe. 

Every  morning  the  head  is  washed 
with  warm  water  and  tar-,  ichthyol-,  or 
naphthol-  soap,  followed  by  rubbing  in 
a  weak  alcoholic  liniment: — 

^  Spirit  of  lavender,  4  ounces. 
Salol  or  salicylic  acid,  7  V2  grains. 
— M. 

Every  evening  the  following  ointment 
should  be  applied: — 
^  Peruvian  balsam 

Salicylic  acid, 

Eesorcin,  of  each,  15  grains. 

Precipitated  sulphur,  3^/2  drachms. 

Lanolin, 

Vaselin,  of  each,  14  drachms. 


Every  morning  the  patches  and  their 
immediate  neighborhood  should  be 
lightly  rubbed  with  a  piece  of  absorbent 
cotton  dipped  in  the  following  solution: 

3^  Chloral-hydrate,  4  scruples. 
Ether,  7  drachms. 
Crystallized  acetic  acid,  15  to  60 
grains. — M. 

Or  in  a  mixture  of  acetic  acid  and 
chloroform  varying  in  strength  accord- 
ing to  the  susceptibility  of  the  patient. 

If  the  face  be  affected,  it  should  be 
washed  every  morning  with  warm  water 
to  which  a  small  quantity  of  one  of  the 
antiparasitic  solutions  mentioned  above 
has  been  added. 

When  the  trunk  and  limbs  are  affected 
the  treatment  should  consist  in  sulphur, 
salt,  with  electric  baths,  and  in  rubbing 
the  body  with  a  horse-hair  brush  dipped 
in  a  stimulating  liquid: — 

IJ  Eesorcin,  2  drachms. 

Orange-flower  water,  12  ounces. — 
M. 

Morrow  recommends  the  following 
procedures: — 

Constitutional  means  of  improving 
the  general  nutrition  are  at  once  begun. 
The  hair  is  clipped  around  the  affected 
patches,  the  loose  hairs  are  removed, 
and  the  following  preparations  are  then 
applied: — 

^   Chrysarobin,  SO  to  40  grains. 

With  or  without 

Salicylic  acid,  10  to  15  grains. 
Ointment  of  gutta-percha,  1  ounce. 

A  moderate  dermatitis  should  be  ex- 
cited and  maintained. 

When  the  alopecia  is  severe  and  ex- 
tensive the  scalp  is  shaved  and  acetic 
acid  is  applied  in  greater  or  less  propor- 
tion, mixed  with  equal  parts  of  ehloro- 


248 


ALOPECIA  AREATA.    TREATMENT. 


form  or  ether,  producing  a  superficial 
vesiculation  followed  by  desquamation. 
Between  the  applications  the  bald 
spots  are  anointed  with  a  stimulating 
oil:— 

^  Eucalyptus, 

Turpentine,  of  each,  '/o  ounce. 
Crude  petroleum. 
Alcohol,  of  each,  1  ounce. — M. 
This  is  followed  by  a  thorough  mass- 
age of  .the  scalp  by  the  patient.    Once  a 
week  or  oftener  the  scalp  is  thoroughly 
shampooed  with  tincture  of  green  soap. 
At  a  later  stage  sulphur  and  resorcin 
ointments  and  salt-water  douches  may 
be  used. 

For  the  face  weaker  solutions  of  acetic 
acid  should  be  employed,  or  applications 
of  a  mixture  of  equal  parts  of  tincture 
of  capsicum  or  tincture  of  cantharides 
and  glycerin  be  made.  For  the  body 
mercurial  and  tar-  soaps  and  sulphur- 
baths  are  to  be  used. 

Chrysarobin  is  the  best  remedy,  pre- 
pared as  follows:    A  stick  composed  of 
R  Chrysarobin,  30  parts; 
Resin,  5  parts; 
Yellow  ointment,  3.5  parts; 
Olive-oil,  30  parts; 
is  rubbed  every  evening  over  the  affected 
part,  which  is  washed  clean  with  olive- 
oil  in  the  morning.     In  some  days  the 
skin   becomes   irritable    and   red,   when 
zinc  ointment  is  substituted  for  a  time. 
Leistikow  (Ther.  Monat.,  Jan.,  '94). 

Pilocarpine,  locally  and  internally,  has 
been  recommended,  but  this  agent  is  ex- 
pensive :  a  fact  militating  against  its  use 
in  ointments. 

The  following  ointment  is  highly  rec- 
ommended:— 
R  Pilocarpine, 

Quinine,  of  each,  4  parts. 
Precipitated  sulphur,  10  parts. 
Balsam  of  Peru,  20  parts. 
Beef-marrow,  100  parts. — M. 
Sabouraud    (Concours  Med.,  June   19, 
'97). 


Pilocarpine  acts  not  only  in  increasing 
perspiration,  but  produces  also  marked 
and  persistent  vasodilatation,  which  in- 
creases the  nutrition  of  the  hair-bulb. 
He  employs  the  nitrate  in  solution  of  Va 
per  cent.,  mixed  with  1  to  1000  bichlo- 
ride of  mercury,  by  intradermie  injec- 
tion. Before  injecting  the  plaque  is 
rubbed  with  90-per-cent.  alcohol.  The 
syringe  is  filled  three-quarters  full  by 
drawing  in  first  Vj  cubic  centimetre  of 
the  mercurial  solution,  then  ^/.,  cubic 
centimetre  of  the  pilocarpine  solution, 
and  finally  '/^  cubic  centimetre  of  the 
mercurial  solution.  This  makes  the 
proper  proportion.  The  injections  are 
made  just  beneath  the  skin  in  as  hori- 
zontal a  manner  as  possible,  1  centimetre 
apart,  and  repeated  every  four  or  five 
days.  A  patch  the  size  of  a  dollar  requires 
about  12  injections.  After  four  or  five 
sittings  the  hair  begins  to  grow.  In 
sixty  cases  treated  over  a  period  of  three 
years  there  was  no  instance  of  failure. 
Scheffer  (La  Med.  Mod.,  May  19,  1900). 

Eesorcin  has  given  satisfactory  results 
in  the  early  stages. 

Electricity  is  sometimes  of  value.  The 
negative  pole  of  a  battery  of  from  four 
to  ten  cells  should  be  applied  to  the  bald 
spot  stifficiently  long  to  produce  a  red- 
ness of  the  skin.  It  should  be  used  only 
in  connection  with  other  remedies. 
(Hayes.) 

An  ointment  of  chrysarobin,  from  3  to 
10  per  cent,  in  strength,  can  be  recom- 
mended as  an  effective  application.  In 
prescribing  this  the  physician  must  not 
forget  to  mention  the  fact  that  it  will 
stain  the  bed-linen,  and  caution  the 
patient  not  to  get  any  ointment  in  his 
eyes  lest  a  severe  conjunctivitis  result. 
George  Henry  Fox  (Amer.  .Jour,  of 
Obst.,  Jan.,  '96). 

Treatment  by  the  arc  light,  the  bald 
spots  and  their  shaved  borders  being 
subjected  to  daily  treatment  of  an  hour 
and  a  quarter's  duration.  The  number 
of  sittings  varied  in  accordance  with  the 
size  and  number  of  the  spots.  The  re- 
sults were  good,  the  hair  beginning  to 
grow  in  a  short  time.  In  one  case  two 
or  three  bald  spots  were  treated  with 


ALOPECIA  AREATA. 


249 


the  light;  these  became  completely  cov- 
ered with  hair,  while  the  untreated  spots 
remained  hairless  until  treated  later  in 
the  same  manner.  Jersild  (Annales  de 
Dermat.  et  de  Syph.,  Jan.,  '99). 

Case  of  a  successful  cvire  in  four 
months  by  x-rays.  The  patient,  a  male 
aged  18,  suffered  from  several  patches 
for  five  months.  The  patches  varied 
in  size  from  a  pea  to  an-  egg.  As  a 
control  experiment  one  patch  was  not 
treated  by  the  rays,  but  an  area  cover- 
ing the  other  patches,  together  with 
the  healthy  scalp,  was  exposed  for  a 
total  period  of  two  hours,  made  up  of 
frequent  short  exposures.  A  week  after 
exposure  the  hair  fell  off  all  the  ex- 
posed parts.  In  three  weeks  the  alo- 
pecia areas  became  red;  the  normal 
areas  were  bald,  but  not  red.  In  an- 
other month  there  was  a  growth  of  new 
hair  on  the  alopecia  spots,  while  the 
rest  of  the  scalp  remained  bald.  The 
condition  was  thus  the  reverse  of  that 
at  the  beginning  of  treatment.  After 
four  months'  treatment  the  whole  area 
exposed  was  covered  with  hair;  the  un- 
treated patch,  however,  was  still  bald. 
This  was  afterward  cured.  The  author 
does  not  consider  the  effect  due  to  bac- 
tericidal action,  as  he  finds  that  expo- 
sure of  bacteria  to  the  strongest  rays  at 
a  focal  fiiteen  centimetres  for  an  hour 
only  hinders  their  growth  for  a  time. 
The  same  exposure  to  the  scalp  would 
cause  severe  ulceration.  Holzkneeht 
(Wiener  klin.  Rund.,  Oct.  9,  1901). 
Geokge  H.  Rohe, 

Baltimore. 

ALUM. — The  alum  generally  used  is 
an  aliTminium  and  potassium  sulphate. 
This  salt  is  likewise  official  in  the  U.  S. 
P.  It  occurs  in  the  form  of  translucent, 
whitish,  octahedral  crystals  having  a 
sweetish  and  strongly-astringent  taste. 
Alum  is  soluble  in  water,  insoluble  in 
alcohol,  and  soluble  in  heated  glycerin. 

Physiological  Action.  —  Alum  is  an 
active  astringent.  It  coagulates  albu- 
min, and  when,  therefore,  it  is  applied  to 
moist  mxicous  membranes,  it  causes  them 
to  turn  white. .  This  is  intensified  by  its 


power  over  the  blood-vessels  of  the  part, 
which  it  firmly  contracts,  probably  by 
stimulating  the  local  vasomotor  nerves. 
It  also  contracts  the  tissues,  depleting 
them  of  their  blood.  Upon  the  blood 
itself  it  acts  as  an  effective  coagulant, 
and  is,  therefore,  an  excellent  styptic. 

When  administered  to  animals,  such  as 
dogs,  eats,  and  rabbits,  by  subcutaneous 
injection,  a  soluble  salt  of  alum  caitses 
no  symptoms  at  all  for  three  or  four 
days.  Then  the  animal  experimented 
upon  suffers  from  loss  of  appetite  and 
obstinate  constipation,  emaciation,  lan- 
guor, and  disinclination  to  move.  Xext 
there  is  vomiting  and  loss  of  sensibility, 
as  a  deep  prick  with  a  needle  is  scarcely 
felt.  When  forced  to  move,  the  leg  is 
raised,  but  trembles  and  twitches  vio- 
lently, and  is  with  difficulty  placed  on 
the  ground.  Sometimes  there  is  general 
tremor  or  convulsive  twitching  and 
sometimes  extreme  weakness  or  partial 
paralysis  of  the  posterior  extremities. 
There  is  complete  loss  of  sensibility  to 
pain,  while  the  animal  retains  its  senses. 
Then  the  power  of  moving  the  tongue 
and  of  swallowing  is  completely  lost; 
even  the  saliva  cannot  be  swallowed. 
The  symptoms  are  precisely  those  of 
human  acute  bulbar  paralysis.  (Mayer 
and  Siem.) 

Case  in  which,  through  gargling  with 
a  concentrated  alum  solution,  a  portion 
of  the  fluid  was  accidentally  swallowed. 
This  was  followed  by  severe  abdominal 
pains,  vomiting  of  mucus  and  blood 
(thirty-nine  times),  and  voiding  of 
blood-stained  urine.  Recovery  only 
after  the  lapse  of  thirteen  days.  Kra- 
molin   (Therap.  ilonats.,  32.5,  1902). 

Alum  is  credited  with  antiseptic  power 
by  some  observers:  a  quality  probably  due 
to  its  property  of  coagulating  albuminoid 
bodies.  When  ingested  in  sufficient 
quantities  alum  irritates  the  gastric  mu- 
cous membrane  and  causes  vomiting. 


250 


ALUMINIUM. 


Therapeutics. — Alum  may  be  said  to 
be  useful  as  an  astringent  in  all  catar- 
rhal conditions  of  the  mucous  mem- 
branes— those  of  the  upper  air-passages, 
the  vagina,  and  the  urethra  particularly 
— in  aqueous  solutions  of  from  5  to  20 
grains  to  the  ounce.  Strong  solutions 
are  rarely  indicated,  their  secondary  ef- 
fects being  those  of  undue  stimulation, 
namely:   irritation. 

Laeyngologt.  —  In  diseases  of  the 
nose  and  throat  the  best  effects  are 
obtained  from  a  15-grain-to-the-ounce 
solution  frequently  applied.  In  acute 
coryza  the  following  snuff  is  effective  if 
used  early: — ■ 

R  Alum,  3  grains. 

Morphine  sulphate,  3  grains. 

Cocaine  hydrochlorate,  1  grain. 

Camphor, 

Bismuth,  of  each,  2  drachms. 

To  be  thoroughly  mixed. 

Sig.:  To  be  used  as  snuff  every  two 
hours,  a  small  quantity  being  used  in 
each  nostril. 

The  giycerite  of  alum  (a  10-  to  20- 
per-cent.  solution  of  alum  in  glycerin 
— heat  is  necessary  to  produce  such  a 
solution  of  the  salt)  is  very  effective  in 
subacute  inflammatory  disorders  of  the 
pharynx  and  larynx,  especially  if  there 
is  a  tendency  to  oedematous  infiltration. 

As  a  styptic  alum  is  a  valuable  agent. 
It  is  foiind  almost  everywhere  and  is 
easily  dissolved  with  the  fluid  always  at 
hand,  water. 

Typhoid  Fever.  —  As  an  astringent 
for  the  intestinal  hsemorrhage  sometimes 
occurring  in  the  course  of  this  disease 
it  has  been  recommended  by  many  cli- 
nicians, Whitla  especially.  It  is  also 
thought  to  act  as  an  antiseptic. 

Epistaxis. — In  epistaxis  alum  some- 
times acts  rapidly,  a  saturated  solution 
being  used.     Pledgets  of  cotton  dipped 


in  this  solution  are  packed  in  the  bleed- 
ing cavity  and  left  in  until  all  danger  of 
recurrence  has  passed:  generally  about 
twelve  hours.  The  solution  may  be 
sprayed  in  in  slight  hemorrhages  or 
powdered  alum  may  be  taken  as  snuff. 

Meteoeehagia. — In  uterine  hasmor- 
rhages  of  all  kinds  alum  is  an  excellent 
styptic.  E.  Beverly  Cole  has  recom- 
mended the  insertion  into  the  uterine 
cavity  of  an  egg-shaped  piece  of  alum. 
The  styptic  effect  is  not  only  produced, 
but  the  tissues  and  the  organ  itself  are 
stimulated  and  caused  to  firmly  contract. 

Ceoup. — As  an  emetic,  alixm  is  very 
frequently  employed  in  children.  A  tea- 
spoonful  may  be  dissolved  in  six  table- 
spoonfuls  of  syrup  and  water,  equal  parts, 
and  a  teaspoonful  administered  every 
fifteen  minutes  until  the  desired  effect 
is  produced.  This  sometimes  serves  to 
quickly  arrest  an  impending  attack  of 
croup,  the  astringent  effect  of  the  salt 
upon  the  mucosa  of  the  throat  counter- 
acting the  local  hypersemia. 

ALUMINIUM.  —  Numerous  prepa- 
rations have  been  obtained  from  this 
metal:  a  boroformate,  a  borotartrate,  a 
hydrate,  a  borotannate,  and  a  sulphate. 
The  double  salts  of  aluminium  are  rec- 
ommended as  powerful  antiseptics,  supe- 
rior to  carbolic  acid  and  sublimate  in 
being  strongly  disinfecting,  though  but 
slightly  poisonous.  The  best  of  them  is 
the  acetotartrate,  prepared  by  mixing 
a  5  to  100  solution  of  basic  acetate  of 
aluminium  with  a  2  to  100  solution  of 
tartaric  acid  and  evaporating  to  dryness. 
It  crystallizes  in  shining  needles,  which 
smell  slightly  of  acetic  acid  and  are  freely 
soluble  in  water,  but  insoluble  in  alcohol. 
(Athenstadt.) 

Boroformate.  —  The  boroformate  is 
a  valuable  preparation  which  combines 
astringent  and  antiseptic  properties,  al- 


ALUMINIUM. 


ALUMNOL. 


251 


though  the  latter  cannot  be  considered 
as  being  marlced.  It  occurs  in  the  form 
of  pearly  scales  crystallized  from  a  solu- 
tion prepared  by  saturating,  with  freshly 
precipitated  and  well-washed  aluminium, 
a  solution  of  2  parts  of  formic  acid  and 
1  part  of  boric  in  6  or  7  parts  of  water. 
It  is  an  hygroscopic  salt,  dissolving  com- 
pletely, though  slowly,  in  water.  The 
solution  has  an  astringent,  sweet  taste, 
and  does  not  coagulate  solutions  of  albu- 
min. 

Boroformate   of   aluminium   has   been 
used  in  the  Prince  of  Oldenberg's  Chil- 
dren's Hospital  at  St.  Petersburg,  where 
it  has  supplanted  all  other  preparations 
of  aluminium.     Martenson   (Pharmaceu- 
tische  Centralhalle  fUr  Deutschland,  No. 
41,  '94). 
Borotartrate.  ■ —  The   borotartrate,    or 
"''boral,"  is  a  combination  of  aluminium, 
boric  acid,  and  tartaric  acid,  and  forms 
w^hite    crystals,   non-irritant,    antiseptic, 
freely  soluble  in  water,  and  valuable  in 
■diseases  of  the  nose  and  naso-pharynx; 
it  is  useful  in  erysipelas,  and,  in  solution 
with  tartaric  acid,  has  given  good  results 
in  gonorrhoea. 

Borotannate.  —  The  borotannate,  or 
"cutol,"  is  a  combination  of  aluminium, 
boric  acid,  and  tannic  acid,  and  is  a 
b)rownish,  insoluble  powder.  It  com- 
bines with  tartaric  acid  to  form  soluble 
cutol.  Cutol  may  be  prescribed  for  oint- 
ment and  is  of  great  service  in  the  treat- 
ment of  weeping  eczema  and  pruriginous 
affections  in  the  following  formula: — • 
T^  Cutol,  1  drachm. 

Olive-oil,  2  ^/„  drachms. 

Lanolin,  q.  s.  to  make  10  drachms. 

When  the  secretion  has  disappeared 
the  following  powder  may  be  used:— - 
19  Cutol, 

Oxide  of  zinc. 

Talc,  of  each,  2  V„  drachms. 
Soluble   cutol  gives   good   results   in 


the  treatment  of  burns  of  the  second  de- 
gree, and  a  solution  of  soluble  cutol  and 
glycerin,  1  to  10,  applied  locally,  causes 
rapid  retrogression  of  follicular  angina. 
The  same  solution  may  be  employed  in 
catarrhal  metritis.  Cutol  may  also  be 
employed  in  the  treatment  of  hemor- 
rhoids. 

For  liEemorrhoids  an  ointment  contain- 
ing 10  per  cent,  of  cutol  may  be  applied, 
while  fissures  of  the  hands  may  be 
treated  by  applications  of 

R  Cutol,  Vi  drachm. 
Oil  of  sweet  almonds, 
Lanolin,  of  each,  3  Vt  drachms. 
Orange-flower      water,      2  Vi     flui- 
drachms. 

Koppel  (Ther.  Monat.,  Nov.,  '9.5). 

Hydrate. — The  hydrate  of  aluminium 
is  prepared,  by  decomposing  a  solution 
of  an  aluminium  salt  by  an  alkali  or 
alkaline  carbonate.  It  is  a  light,  white 
powder,  soluble  in  acids  and  fixed  alka- 
lies. This  is  also  a  light  astringent,  em- 
ployed in  skin  afEections. 

Sulphate.  —  The  sulphate  of  alumin- 
ium, prepared  by  dissolving  aluminium 
hydrate  in  sulphiiric  acid,  is  soluble  in 
water,  but  insoluble  in  alcohol.  Injected 
in  the  blood  it  induces  powerful  contrac- 
tion in  the  capillaries,  especially  those  of 
the  lung.  It  is  used  in  strong  solution 
as  an  antiseptic  in  diseases  of  the  nose, 
throat,  uterus,  and  vagina,  and  as  a  lotion 
for  foul  ulcers,  vaginal  discharges,  etc. 

ALUMNOL  is  an  aluminium  salt  of 
the  naphthol-sulphur  acids.  It  is  a  fine, 
white,  non-hygroscopic  powder,  easily 
soluble  in  cold  water,  slightly  so  in  alco- 
hol, and  insoluble  in  ether.  Its  unirri- 
tating  quality  in  weak  solutions  makes 
it  available  for  the  treatment  of  cavity 
wounds  and  chronic  catarrhal  processes. 
In  acute  cases,  however,  it  is  usually  irri- 
tating. 

Mode  of  Employment.  —  It  is  not  in- 


252 


alujMnol.   therapeutics. 


compatible  with  sublimate,  resorcin,  etc., 
and  may  be  combined  with  them  in  order 
to  strengthen  their  reciprocal  action,  if 
it  is  desired  to  combine  the  action  of 
several  antiseptics. 

Therapeutics.  —  A  general  review  of 
the  literature  does  not  warrant  a  final 
opinion  as  to  its  merits,  but  the  pub- 
lished reports,  a  few  of  which  are  given 
below,  do  not  indicate  that  it  is  worthy 
of  much  confidence  in  the  treatment 
of  the  genito-urinary  tract:  its  main 
stronghold.  It  has  been  tried  in  gynfe- 
cological,  dermatological,  surgical,  and 
laryngological  eases  as  an  astringent,  and 
when  used  in  weak  solutions  seems  to 
have  given  more  encouraging  results. 

Gynecology. — In  V2  to  1-per-cent. 
solution  it  has  been  found  useful  in  en- 
dometritis of  gonorrhoeal  origin,  and  in 
colpitis,  if  non-gonorrhceal  in  character. 
(Heinze  and  Liebreich.) 

Used  in  sixteen  gynsecological  cases: 
catarrh  of  the  neck  and  endometritis 
with  or  without  inflammation  of  the 
annexa.  Cervical  catarrh  and  simple 
perimetritis  yielded  to  its  repeated  use. 
In  endometritis  complicated  with  lesions 
of  the  annexa  the  pains  were  augmented 
on  account  of  the  irritation  produced. 
Gonorrhoeal  vaginitis  was  readily  cured. 
The  following  preparations  were  used: 
A  solution  of  3  per  cent,  for  lavages;  a 
powder  and  bougies  of  20  per  cent.;  and 
a  10-per-cent.  solution  as  an  astringent 
in  the  treatment  of  endometritis  and  of 
erosions.  A.  Kontz  (Wiener  med.  Presse, 
No.  18,  '93). 

Tried  in  12  cases  of  acute  gonorrhcea, 
20  chronic  cases  (in  8  of  which  gonocoeci 
were  present),  4  cases  of  gonorrhceal  epi- 
didymitis, 2  of  post-gonorrhoeal  adenitis, 
and  2  of  soft  chancre.  In  the  first  cases 
mentioned,  treatment  was  begun  by 
intra-urethral  injections  of  a  1-  to  2-per- 
cent, solution  of  alumnol  three  times 
daily.  Later  the  same  solution  was  used 
once  daily,  or  else  a  feebler  solution 
(from  0.25  to  1.00  per  cent.)  several 
times   during  the  twenty-four  hours.    In 


8  cases  treatment  was  begun  from  one 
to  three  days  after  the  appearance  of  the 
secretion,  and  from  three  to  ten  days  in 
the  other  4  cases.  The  drug  was  not 
found  superior  to  any  other  drug  gener- 
ally used.  Found  inferior  to  nitrate  of 
silver.  Cases  of  soft  chanei-e  were  the 
ones  cured.  Casper  (Berliner  klin. 
Woch.,  No.  13,  '94). 

That  alumnol  does  not  possess  the 
antigonorrhoeal  merits  granted  it  by 
Chotzen  shoAvn  by  a  trial  in  twelve  cases. 
E.  Samter  (Berliner  klin.  Woch.,  No.  13, 
'94). 

Marfan  uses  bougies  of  alumnol,  3  per 
cent.,  in  the  treatment  of  vulvo-vaginitis. 
M.  Storer  (Boston  Med.  and  Surg.  Jour., 
Jan.  20,  '98). 
Surgical  Dressing. — In  the  dressing 
of  wounds  and  in  ulcerations  of  specific 
or  non-specifie  character  it  produces,  ac- 
cording to  Eraud,  no  irritation  or  pain. 
This  author  considers  it  as  efficacious 
as  other  powders  for  the  desiccation  of 
wounds.    It  appeared  to  be  useful  in  cer- 
tain varieties  of  pruritus,  especially  that 
of  the  anus  and  scrotum. 

Laryngology.  —  Alumnol  has  been 
found  valuable  in  simple  chronic  and 
hypertrophic  rhinitis,  ozjena,  catarrhal 
and  follicular  tonsillitis,  and  acute  and 
chronic  catarrhal  and  follicular  phar- 
yngitis, in  a  1-per-cent.  sohition  as  a 
douche;  in  a  watery,  glycerin  solution 
(1  to  5)  for  application  to  the  affected 
parts;  or  in  a  powder  mixed  with  starch 
(10  to  20  per  cent.)  for  insufflation. 

In  acute  laryngeal  afi^eetions  the 
roughness  of  voice  generally  disappeared 
after  a  single  inhalation  of  a  1-per-cent. 
solution.  In  chronic  eases  good  results 
were  obtained  by  the  use  of  insufflations 
of  a  mi.xture  of  alumnol  and  starch  (2 
to  10  per  cent.).  A  1-per-cent.  solution 
was  of  signal  service  as  an  hfemcstatic  in 
cases  of  haemoptysis.  A.  Stepanicz  (An- 
nual, '95). 

Two  years'  experience  showing  that 
alumnol  is  of  the  greatest  value  as  an 
astringent,  especially  in  conditions  ac- 
companied by  oedema,  whatever  be  the 


AMENOERHCEA. 


253 


direct    cause    of    the    latter.      Metzerott 
(Amer.  Therapist,  Sept.,  '97). 

Deematology.  —  It  has  been  found 
useful  in  powder,  13  to  25  per  cent.; 
collodion,  5-  to  lO-per-cent.  strength; 
and  ointment,  1,  5,  and  12  V2  P^r  cent., 
in  dermatitis,  in  acute  eczemas  of  all 
sorts,  in  chronic  eczemas;  in  syphilis  and 
the  parasitic  skin'  affections  it  was  not 
of  much  benefit.  In  acne  and  rosacea 
as  good  results  have  been  obtained  by 
it  as  by  most  methods  of  treatment. 
(Gottheil.) 

Found  efficacious  in  acute  superficial 
inflammatory  affections  of  the  skin,  as 
^^•ell  as  in  chronic  processes  in  which 
the  inflammation  was  deeper;  in  para- 
sitic diseases,  such  as  erysipelas,  favus, 
lupus,  soft  chancre,  and  erosions;  and 
in  acute  and  chronic  inflammations  of 
the  mucous  membrane.  Chotzen  (Ber- 
liner klin.  Woch.,  No.  48,  '92). 

AMENOERHCEA.  —  (Lat.).  From  d, 
priv.;  [.lYjv,  a  mouth;   and  pdi',  to  flow. 

Definition. — Absence  of  the  menstrual 
flow  in  women  of  a  suitable  age  who  are 
not  pregnant.  Suppression  of  menses, 
the  menstruation  having  ceased  through 
some  local  or  remote  disorder,  is  also 
termed  amenorrhcea. 

Varieties. — Amenorrhcea  may  be  com- 
plete, when  the  menstruations  have  com- 
pletely ceased;  comparative,  when  it  ap- 
pears occasionally;  primary,  when  the 
menstruation  has  not  presented  itself 
at  the  age  of  puberty  nor  subsequently; 
secondary,  transitory  or  accidental,  or 
when,  having  already  appeared,  the  men- 
struation ceases. 

Symptoms. — No  other  symptom  than 
absence  of  the  menstruation  may  be  pres- 
ent, or  the  monthly  flow  may  be  absent 
and  the  general  attendant  phenomena 
usually  preceding  menstruation  occur. 
Frequently  the  patient  complains  of 
headache,  heat-flashes,  fever,  nausea  and 


vomiting,  and  heaviness  in  the  abdomen. 
Concomitant  nervous  disorders  may  form 
the  basis  of  acute  manifestations,  hys- 
terical especially.  "When  the  retention  is 
due  to  uterine  stricture,  there  is  consid- 
erable pain  radiating  from  the  uterus 
to  the  surrounding  parts,  including  the 
lumbar  region. 

Pure  suppression  of  the  menstruation 
usually  gives  rise  to  no  symptoms,  espe- 
cially when  the  impending  general  dis- 
order is  the  cause  of  the  amenorrhcea. 
Wlien,  however,  it  is  due  to  a  local  dis- 
turbance, the  symptoms  of  a  congestive 
disorder  of  the  genital  tract  appear,  soon 
followed  by  an  inflammatory  process, 
which  may  be  general  or  local.  Peri- 
tonitis sometimes  appears  as  a  result  of 
such  a  process.  Eemote  symptoms  may 
also  present  themselves,  doubtless  of 
reflex  origin. 

Amenorrhcea  virginalis  a  new  disease, 
in  no  way  connected  with  cessation  of 
menstruation  from  chlorosis,  anaemia, 
etc.,  which  occurs  in  young  women.  The 
first  symptom  is  the  amenorrliosa,  which 
may  or  may  not  be  associated  with 
vicarious  menstruation.  After  awhile 
cardiac  symptoms  supervene,  especially 
palpitation,  dyspncea,  and  cyanosis;  the 
right  heart  fails,  and  cedema  and  death 
result.  Two  such  fatal  cases.  The  sup- 
pression of  the  menses  led  to  general 
plethora,  cardiac  hypertrophy,  valvular 
incompetence,  and  finally  pulmonary  con- 
gestion. Edelheit  (Wiener  med.  Presse, 
Aug.  16,  23,  '97). 

Series  of  cases  which  present  certain 
well-defined  clinical  features.  These 
prominent  characteristics  are:  (1)  di- 
minished or  arrested  menstruation;  (2) 
local  symmetrical  imperfect  oxygenation 
of  the  blood  of  the  extremities,  especially 
the  arms  and  hands — a  condition  known 
as  "Raynaud's  phenomena";  and  (3) 
pulmonary  tuberculosis.  The  presence  of 
any  single  one  of  these  symptoms  in 
patients  is  observed  every  day,  but  at- 
tention has  not  hitherto  been  called  to 
the  remarkable  association  of  all  of  these 
clinical  features  in  the  same  individual. 


254 


AMENORRHCEA.    ETIOLOGY. 


This  trilogy  of  symptoms  did  not  always   I 
appear  contemporaneously  in  any  of  the 
patients    who   are    affected.      In    all    of 
them  when  first  seen  the  local  asphyxia 
and    the    irregularity    of    menstruation 
were   marked;     in   two   of   the   patients 
pulmonary    tuberculosis    was    also    co- 
existent with  the  other  clinical  features 
mentioned,  while  in  two  other  patients 
it    developed    at    a    subsequent    period. 
J.  W.  Byers  (Lancet,  Aug.  26,  '99). 
Etiology. — In  cases  of  primary  men- 
struation  imperfect   or   instifiicient   de- 
velopment is  the  most  usual  cause.     In 
cold  countries,  where  growth  of  the  sys- 
tem at  large  is  more  gradual,  the  men- 
struation   appears    later    than    in    the 
warmer  countries,  where  development  is 
rapid,  but  where,  also,  women  enter  the 
stages  of  decrepitude  earlier.     Anatom- 
ical  imperfections   and   anomalies,   the 
absence  of  any  of  the  genital  organs,  or 
a  rudimentary  or  infantile  utertts  may 
thus  account  for  the  total  absence  of 
menstruation.     Imperforate  hymen  is  a 
frequent,  though  easily  recognized,  cause. 
On  general  principles,  the  causes  of 
amenorrhcea  may  be  divided  into  four 
classes: — 

Nervous  Disoedees. — Grief,  anxietj^, 
fright,  and  anger  are  as  many  possible 
primary  causes,  especially  if  the  patients 
are    poorly    fed.      Women    who    either 
greatly  fear  or  greatly  desire  tO'  become 
pregnant;     newly-married    women,    and 
women  who  are  confined  in  prisons  or 
insane-asylums  furnish  a  large  propor- 
tion of  the  cases.    Eemoval  from  country 
to   city   or  vice  versa,   especially   when 
coupled  with  nostalgia,  is  a  prolific  cause. 
On   general   principles,   change   in   the 
mode  of  living  or  of  climate,  especially 
with  an  intervening  sea-voyage,  appears 
to  frequently  act  as  the  etiological  factor. 
Probably  not  less  than  33  per  cent,  of 
women  emigrants  under  30  years  of  age 
suffer     from     suppressed     menstruation 
after  a  sea-voyage.     Many  have  abdom- 


inal distension,  and  not  infrequently 
girls  have  been  innocently  charged  with 
being  pregnant.  Obstinate  constipation 
a  common  symptom.  The  true  etiology 
is  largely  psychical  and  neurotic.  H.  C. 
Bloom  (Univ.  Med.  Mag.,  Dec,  '96). 

In  those  cases  where  the  follicular 
stroma  of  the  ovary  has  been  the  seat  of 
an  inflammatory  process  during  the  in- 
fectious fevers,  the  patient  may  have  an 
amenon-hosa  which  may  remain  and  be- 
come permanent.  Alexander  Simpson 
(Practitioner,  Aug.,  '98). 

Case  of  a  young  married  woman  who 
found  that,  as  soon  as  she  left  London 
and  went  to  the  country,  her  menstrua- 
tion Avould  return  at  the  regular  times, 
but  would  not  if  she  remained  in  town. 
By  leaving  town  for  two  days  each 
month  it  was  possible  for  her  to  regulate 
the  monthly  function.  W.  J.  H.  Hep- 
worth  (Lancet,  Nov.  10,  1900). 

Geneeal  Affections. — Amenorrhcea 
frequently  occurs  after  a  serious  illness, 
such  as  typhoid  fever,  eruptive  fevers, 
mumps,  pneumonia,  or  during  the  course 
of  any  chronic  disease,  diabetes,  cancer, 
malaria,  at  the  onset  of  severe  syphilis, 
or  when  any  intoxication  of  the  system 
occurs,  as  in  morphinism,  alcoholism, 
and  hydrargyrism. 

Eighteen  cases  in  which  the  morphine 
habit  caused  amenorrhcea.     It  is  usually 
complete    and    accompanied    by    loss    of 
sexual  desirCj  but  the  functions  are  re- 
established    if     the     habit     be     broken. 
Lutaud  (Eevue  G6n.  de  Clin,  et  de  ThSr., 
May  2,  '89). 
It  may  be  consequent  upon  an  acute 
or  chronic  surgical  affection,  a  blow,  or 
injury.     Luxurious  living  and  want  of 
exercise,  obesity,  and  excessive  intellect- 
ual labor  at  the  period  of  puberty,  when 
not   counterbalanced  by  fresh  air   and 
active  exercise,  may  retard  the  develop- 
ment of  the  generative  organs  and  thus 
induce  the  disorder. 

Case  of  a  young  woman  who  presented 
many  of  the  usual  signs  of  pregnancy, 
including  cessation  of  the  menses,  promi- 


AMENOERHCEA.    ETIOLOGY. 


255 


nence  of  the  abdomen,  etc.  On  examina- 
tion deposits  of  adipose  tissue  were  found 
in  the  abdominal  walls,  while  the  uterus 
was  small — smaller,  indeed,  than  usual. 
Subsequent  events  proved  it  to  be  a  ease 
in  which  obesity  had  led  to  disturbance, 
if  not,  indeed,  early  appearance,  of  the 
menstrual  function.  Robert  A.  Keid 
(Mass.  Med.  Jour.,  Aug.,  '98). 

Blood  Disorders  and  Wasting  Dis- 
eases. —  Ansmia  and  idiopathic  chlo- 
rosis, pernicious  ansemia,  leuksemia,  and 
Hodgkin's  disease  are  the  most  promi- 
nent factors.  The  following  causes  of 
waste — and  directly,  therefore,  of  amen- 
orrhcea — are  also  to  be  remembered: 
Haemorrhage,  albuminous  discharges; 
hsemorrhage  from  piles,  scurvy,  purpura, 
and  injury,  as  in  hsemophilia;  hsemor- 
rhage  from  the  stomach,  as  in  gastric 
ulcer;  from  the  lungs,  or  from  the  nose, 
and  from  a  rare  disease  produced  by  a 
parasite  in  the  duodenum:  the  anchy- 
lostoma  duodenale.  Long-continued 
suppuration,  albuminuria,  chronic  diar- 
rhoea, malignant  ulcers,  tubercular  dis- 
ease, all  impoverish  the  blood,  and  so 
may  cause  ansemia.  All  diseases  that 
cause  wasting  of  the  body  finally  cause 
the  menstruation  to  cease.  Chief  among 
these  are  phthisis,  diabetes,  caries  of 
bone,  protracted  or  febrile  illness;  ano- 
rexia nervosa,  the  patient  wasting  be- 
cause she  will  not  eat;  and  gastric  ulcer. 

Lesion  of  Genito-Ueinart  Organs. 
— Any  lesion  of  the  genital  apparatus 
may  cause  amenorrhcea,  especially  me- 
tritis, endometritis,  and  parametritis 
(both  acute  and  chronic),  and  flexion 
or  malposition  of  the  uterus.  Adhesion 
due  to  a  previous  pelvic  peritonitis  is 
an  occasional  cause  of  hyperinvohition 
of  the  uterus  following  pregnancy.  At- 
rophy of  the  ovaries,  senile  atrophy  fol- 
lowing pregnancy,  and  cystic  ovarian  de- 
generation are  among  the  less  common 
etiological    factors.      A    most    complete 


examination  of  the  pelvic  organs  should 
be  made,  if  necessary,  under  ether  in 
such  cases. 

If  menstruation  does  not  appear  at  the 
age  of  puberty,  a  careful  scrutiny  on  the 
part  of  the  physician  is  obligatory  and 
imperative.  Case  of  a  young  woman,  24 
years  of  age,  in  whom  the  amenorrhcea 
Avas  of  organic  origin.  A  dermoid  and 
a  suppurating  multilocular  cyst  were 
found  and  removed:  Report  of  the  pa- 
thologist harmonizes  with  the  theory  of 
the  case  both  from  physiological  and 
pathological  stand-points:  1.  That  the 
dermoid  had  usurped  the  place  and  de- 
stroyed the  function  of  the  right  ovary. 

2.  In  one  of  the  cyst-walls  of  the  mul- 
tilocular ovarian  cyst  was  found  a. 
shrunken  ovary  the  size  of  a  large  lima- 
bean,  and  within  this  ovarian  stroma, 
was  found  a  corpus  luteum  spurium. 
To  the  presence  of  this  ovarian  stroma 
was  due  the  womanly  development,  with, 
ovulation  and  the  futile  effort  of  men- 
struation  and   its   consequent   suffering.. 

3.  The  case  demonstrates  the  possibility 
of  ovulation  without  menstruation.  4. 
It  leaves  doubt  whether  the  absence  of 
the  oviducts  was  primary  or  secondary 
to  the  grave  disease  of  the  ovaries,  with, 
the  possibility  that  they  were  congeci- 
tally  absent.  5.  It  presents  the  rare  and. 
exceptional  condition  of  a  perfectly  de- 
veloped woman  who  had  an  ovary  and. 
a  uterus,  who  ovulated,  was  sterile,  and. 
never  menstruated,  and  yet  was  ruinsd. 
in  health  by  Nature's  effort  to  establish 
an  impossible  normal  function.  W.  B. 
Chase  (Amer.  Jour,  of  Obstet.  and  Dis. 
Women  and  Children,  Oct.,  '98). 

Exposure  to  cold  during  menstruation,, 
by  inducing  congestion  of  the  pelvic  or- 
gans, is  one  of  the  most  active  exciting 
causes,  especially  when  supplemented  by 
a  local  chronic  disorder. 

The  most  important  condition  with, 
which  this  disorder  might  be  confounded 
is  pregnancy.  The  reader  is  referred  to 
the  article  under  that  head. 

Case  of  a  healthy  girl,  aged  15,  who- 
had  been  subject  for  a  year  to  gradual 
swelling   of   the    abdomen.      The   period. 


256      AMENORRHCEA.    PATHOLOGY.    DIAGNOSIS.     PROGNOSIS.     TREATMENT. 


had  ceased  for  two  months  only.     The 
breasts    became    hard    and    tense.      The 
hymen  was  intact.     Peritonitis  of  tuber- 
culous origin  suspected.    On  opening  the 
abdomen  an  enormous  cyst,  which  con- 
tained twenty  pints  of  fluid,  discovered. 
Its  pedicle  was  twisted  and  had  risen  in 
the  parovarium.     On  the  day  after  the 
operation  the  catamenia  reappeared  and 
tlie   abdomen   soon   resumed   its   normal 
form.    Cortiquera  (Anales  de  Obst.,  Gine., 
y  Ped.,  Jan.,  '96). 
Pathology.  —  A  pathological  identity 
can  hardly  be  attributed  to  amenorrhcea, 
owing  to  its  complex  causes,  the  diverse 
physiological  conditions  peculiar  to  the 
cases,  and  the  diathetic  conditions  that 
may  be  present.    The  fact  that  the  true 
nature    of    menstruation    itself    is    not 
known  adds  another  objection;    and  it 
may  safely  be  said  that  the  pathology 
of  amenorrhoea  is  that  of  the  diseases 
causing    it,    until    the    local    disorders 
brought  about  by  each  will  have  been 
determined.    The  following  extracts  are 
given  to  indicate  the  present  trend  of 
thought  regarding  the  cause  of  menstru- 
ation. 

Blood-pressure  varies  greatest  at  the 
commencement  of  menstruation,  least  im- 
mediately after;  remains  about  the  same 
height  seventeen  days,  when  it  again 
begins  to  rise.  Derangement  of  this  cycle 
leads  to  various  pathological  phenomena. 
A.  W.  Johnstone  (Amer.  Jour,  of  Obstet., 
May,  '95). 

Evidence  recently  furnished  by  Heape 
justifying  opinion  that  ovulation  is  not 
tlie  cause  of  menstruation.  We  should 
not  speak  of  menstruation  as  occuiTiiig 
once  a  month,  but  as  occupying  a  whole 
month.  Lawson  Tait  (Provincial  Med. 
Jour.,  Jan.  1,  '95) . 

All  evidence  favors  the  theory  that 
ovulation  and  menstruation  are  inde- 
pendent; ovulation  in  a  modified  form 
continues  during  pregnancy.  Byron 
Robinson  (Amer.  Gyn.  and  Obst.  Jour., 
Aug.,  '95). 

Study  of  over  three  thousand  cases 
showing  that  earlier  menstruation  in 
tropical  countries  is  not  due  to  climate, 


but  to  too  early  sexual  excitement.  Jou- 
bert  (Indian  Med.  Gazette,  Apr.,  '95). 
Diagnosis.  —  Primary  amenorrhcea  — 
that  is,  total  absence  of  menstruation — 
is  usually  due,  as  already  stated,  to  the 
absence  of  one  or  more  of  the  organs 
of  generation.  It  must  be  distinguished 
from  retention  of  the  menses,  due  to 
atresia  of  the  cervical  canal,  of  the  va- 
gina, or  of  the  vulva.  In  the  latter  case 
no  menstruation  has  existed,  but  the 
general  premonitory  symptoms  of  men- 
struation have  occurred,  though  followed 
by  no  menstrual  flow.  Cases  in  which 
one  or  more  of  the  organs  are  absent 
are  not  very  infrequent,  while  cases  of 
imperforate  hymen  are  comparatively 
common. 

Prognosis.  —  Amenorrhcea  due  to  ab- 
sence of  any  of  the  organs  is,  of  course, 
incurable.  The  same  may  be  said  of 
cases  in  which  the  approach  of  meno- 
pause or  other  conditions  pointing  to 
senility  of  the  uterus.  Although  amen- 
orrhcea, when  due  to  a  serious  chronic 
disease,  is  usually  cured  with  difliculty, 
hope  may  always  be  entertained  when  the 
causative  disorder  is  not  in  itself  a  fatal 
one.  Eeturn  of  the  menstruation  in  any 
chronic  disorder,  when  the  blood  presents 
its  normal  appearance,  is  an  encouraging 
sign. 

[The   prognosis   of   secondary   atrophy 
with  amenorrhcea  depends  greatly  on  the 
condition  of  the  ovaries,  and  is  practi- 
cally   hopeless    if    they    are    atrophied. 
MuNDE,  Assoc.  Ed.,  Annual,  '90.] 
Treatment.  —  Women  who  object  to 
becoming  pregnant  represent  a  large  pro- 
portion of  the  cases  of  amenorrhcea  met 
with.    Special  care,  therefore,  should  be 
taken  not  to  administer  emmenagogues, 
under  such  circumstances,  or  to  intro- 
ditce  instruments  into  the  uterus.     In 
bona  fide  cases,  however,  amenorrhoea  be- 
ing more  of  a  symptom  than  a  disease 
per  se,  the  original  cause  should  be  dili- 


AMENORRHCEA.     TREATMENT. 


257 


gently  sought  after  and  removed,  if  pos- 
sible. 

When  diagnosis  between  functional 
amenorrhoea  and  pregnancy  is  difficult, 
aenecio  may  be  safely  prescribed  before 
deciding,  as  it  will  probably  cure  the 
one,  and  certainly  will  do  no  harm  to  the 
other.  Senecio  will  not  cause  abortion 
nor  in  any  way  influence  the  course  of 
pregnancy.  W.  E.  Fothergill  (Edinburgh 
Med.  Jour.,  May,  '98). 

Emmenagogues  may  be  classified  into 
two  classes:  medicinal  and  physiological. 

Severe  physical  shock  or  fright  some- 
times causes  the  menstruation  to  return 
suddenly. 

When  the  arrest  of  menstruation  is 
due  to  exposure  to  cold,  warm  baths 
and  vaginal  injections,  sinapisms  to  the 
thighs  and  calves  of  the  legs,  saline 
laxatives  and  manganese-binoxide  pills 
(3  grains  each),  one  or  two  after  each 
meal,  are  frequently  successful.  This 
drug  acts  by  increasing  the  vascularity  of 
the  pelvic  organs.  The  permanganate  of 
potassium,  or  the  lactate,  in  1-grain  doses 
three  or  four  times  daily,  after  meals,  act 
in  the  same  manner. 

The  following  treatment  is  highly  rec- 
ommended in  suppression  of  the  menses: 
B  Liquor   ferri   et   quinia    citratis,    1 
ounce. 
Liquor  potassii  arsenitis,  3  drachms. 
Sti-ychnine, 

Atropine,  of  each,  V=  grain. 
Elixir    of    orange-peel,    enough    to 
make  8  ounces. 
M.     Sig. :    Teaspoonful  in  water,  before 
meals,  three   times   daily.     The  ingredi- 
ents, or  dose,  to  be  increased  according 
to  the  tolerance  of  the  patient. 

This  is  continued  until  there  is  mani- 
fested the  peculiar  menstrual  discomfort, 
when  it  is  discontinued  and  the  following 
given: — 

IJ  Potassii  permanganatis,  10  grains. 
Divide  into  pills  No.  x,  compressed  or 
in  capsule. 

Sig. :     One   pill   followed   by    one-half- 

1—17 


glassful  of  water,  before  meals,  three 
times  daily. 

Also:  — 

1}  Manganesium  binoxide,  10  grains. 

Divide  into  10  compressed  pills  or  into 
as  many  capsules. 

Sig.:  One  pill  after  each  meal,  three 
times  daily. 

By  the  second  or,  at  most,  the  third 
day  after  taking  these  the  flow  usually 
becomes  fully  established.  If  the  man- 
ganese does  not  fully  effect  this  at  the 
first  attempt,  the  first  prescription  is  re- 
lied on  during  the  interval,  and  the  pills 
commenced  about  three  days  before  the 
expected  time. 

In  ordinary  menstrual  suppression  the 
last  two  formulae,  used  as  above,  are  es- 
pecially effective.  De  Wees  (Med.  and 
Surg.  Reporter,  June  30,  '88). 

In  amenorrhoea,  associated  with  mental 
diseases,  the  potassium  permanganate  is 
to  be  given  in  1-grain  pills  three  times 
daily,  and  after  three  months  in  2-grain 
doses.  The  pills  should  be  given  for  fully 
three  months  after  the  courses  appear, 
and  must  be  taken  without  intermission. 
Macdonald  (London  Practitioner,  June, 
'88). 

Of  the  manganese  compounds  the  bin- 
oxide  seems  to  give  the  best  general  re- 
sults, though  it  cannot  always  be  relied 
upon.  The  lactate  is  also  an  efficient  and 
irritating  agent.  Segur  (Med.  Record, 
Feb.  2,  '89). 

When  manganese-binoxide  pills  are 
given  they  should  be  followed  by  a  little 
water  fifteen  minutes  later,  in  order  to 
avoid  the  burning  pain  in  the  stomach, 
which  they  are  liable  to  cause.  E.  J. 
Hauck  (Va.  Med.  Monthly,  Aug.  30,  '91). 

When  there  is  any  faulty  constitu- 
tional condition,  this  should  be  treated. 
Anaemia  especially  requires  iron  with  ar- 
senic and  strychnine  or  nux  vomica,  and, 
as  the  ansemia  improves,  menstruation  is 
more  likely  to  be  established.  As  to  the 
action  of  reputed  emmenagogues,  such  as 
manganese  dioxide,  potassium  perman- 
ganate, senecin,  etc.,  the  results  in  per- 
sonal experience  have  not  been  encour- 
aging. After  a  reasonable  trial  of  drugs, 
if  no  result  is  obtained,  it  is  usually  ad- 


258 


AMENOERHCEA.    TREATMENT. 


visable  to  examine  the  pelvic  organs, 
preferably  nnder  an  anaesthetic,  for,  if 
a  condition  of  under-development  be 
present,  prolonged  drug  treatment  is 
futile,  and  is  disappointing  to  the  pa- 
tient. Under  these  circumstances  it  is 
best  to  explain  the  condition  and  leave 
matters  alone.  Stimulation  by  electric- 
ity is  usually  undesirable  and  unneces- 
sary in  the  ease  of  single  patients, 
though  it  may  be  tried  in  exceptional 
cases  if  the  fact  of  amenorrhoea  is  a 
source  of  worry  to  the  patient.  The 
most  effective  stimulus  is  that  supplied 
by  marriage.  A.  E.  Giles  (Clinical  Jour., 
Jan.  30,  1901). 

In  the  amenorrlicea  following  sea- 
voyages  the  preparations  of  manganese 
and  oxalic  acid  hold  the  first  place. 

In  amenorrhcea  following  a  sea-voyage 
a  valuable  combination  is  peptonate  of 
iron  with  manganese.  Oxalic  acid  com- 
bined with  the  iron  and  manganese  in 
the  following  formula  especially  valu- 
able:— 

3  Oxalic  acid,  4  grains. 

Peptonate  of  iron,  46  grains. 
Peptonat '  of  manganese,  160  grains. 
Elixir  of  Curasoa,  2  ounces. 
Water,  6  ounces. 
M.     Sig.:    A  tablespoonful  in  a  glass 
of  milk  three  times  a  day. 

This  simple  plan,  with  a  well-regulated 
diet  of  eggs,  fish,  meats,  oysters,  milk, 
and  vegetables  that  are  rich  in  organic 
iron  may  be  all  that  is  required.  H.  C. 
Bloom  (Univ.  Med.  Mag.,  Dec,  '96). 

When  the  manganese  preparations  fail, 
santonin,  10-grain  doses  at  bed-time,  is 
especially  valnable  in  chlorotic  subjects. 

[Santonin,  given  in  10-grain  doses  at 
night,  is  a  most  reliable  emmenagogue, 
particularly  in  chlorotic  patients.  Ex- 
perience based  upon  a  large  number  of 
cases.     RiNGEE.  Corr.  Ed.,  Annual,  '89.] 

[We  have  seen  it  used  with  good  effect. 
MuNDE  and  Wells,  Assoc.  Eds.,  Annual, 
'89.] 

The  preparations  of  manganese  and 
santonin  may  be  given  simultaneously: 
1  grain  of  santonin  at  night  and  potas- 
sium permanganate  -n  1-  to  2-grain  doses 


thrice   daily.     Panecki    (Amer.   Jour,  of 
the  Med.   Sciences,  July,  '94). 

Senecio  jacobtea  is  useful  in  functional 
amenorrhoea,  as  it  not  only  anticipates 
the  period,  but  increases  the  quantity. 
In  many  cases  it  relieves  the  accompany- 
ing pain  and  not  infrequently  the  head- 
aches from  which  some  women  suffer  at 
such  periods.  The  action  of  senecio 
jacobaea  resembles  that  of  potassium  per- 
manganate and  is  especially  valuable  in 
functional  amenorrhoea.  It  causes  the 
regularity  and  the  copiousness  of  the 
flow.  William  Murrell  (Brit.  Med.  Jour., 
Mar.  31,  '94). 

In  stout  chlorotics  the  amenorrhoea 
should  be  combated  by  tincture  of  sene- 
cio vulgaris,  in  I-  to  2-drachm  doses 
three  times  daily.  This  drug  tends  to 
reduce  the  local  pain  and  the  headache. 
R.  J.  E.  Young  (Edinburgh  Med.  Jour., 
Sept.,  '94). 

Six  cases.  Blood-count  in  one  case 
showed:  red  cells,  3,000,000;  hemoglo- 
bin, 52  per  cent.  Placed  on  ferratin, 
8  grains  four  times  daily,  with  aloetic 
purges,  combined  with  perfect  rest,  and 
rose  to:  red  cells,  4,600,000;  haemoglo- 
bin, 92  per  cent. 

The  following  combination  is  recom- 
mended:— 

B  Ferratin,  3  drachms. 
Ext.  of  aloes,  14  grains. 
Ext.  rhei  comp.,  9  grains. 
M.     Sig.:    Make  into  30  tablets;    take 
1  or  2  tablets  twice  daily.    C.  E.  Williams 
(Amer.  Therapist,  Aug.,  '97). 

In  amenorrhoea,  following  combination 
gives  good  results: — 
R   ]\Iyrrh, 
Aloes, 

Reduced  iron,  of  each,  75  grains. 
Extract  of  valerian,  a  sufficiency. 
M.     Divide  into   120  pills,  to  be  kept 
in  powdered  cinnamon.     Dose,  five  pills 
three  times  a  day.     Oesterlen   (Centralb. 
f.  die  gesammte  Ther.,  Feb.,  '98). 
The  general  system  should  be  invig- 
orated by  attention  to  diet,  sleep,  and 
clothing.      Out-of-door,    light    exercise 
and  sunlight  are  most  important.     This 
is  especially  the  case  when  there  is  rap- 
idly increasing   obesity.     In  the   latter 


AMENORRHCEA.    TREATMENT. 


259 


case  the  diet  should  be  regulated,  saline 
laxatives  administered,  or  a  cure  at 
Marienbad  recommended.  Stimulation 
of  the  ovaries  and  uterus  by  the  faradic 
current  is  especially  efficient  in  these 
cases. 

Cupping  or  scarifying  the  cervix  is 
sometimes  successful.  These  means  in- 
crease the  pelvic  congestion  and  tend  to 
counteract  uterine  or  ovarian  torpidity. 
Eudimentary  organs  or  atrophy  of  the 
uterus,  if  not  too  great,  should  be  treated 
by  dilatation  of  the  uterus  with  tents 
and  stimulated  by  tlie  faradic  current. 
Exercise  and  nourishing  food  should  also 
be  given.  Sea-bathing  is  of  assistance 
in  such  cases. 

The  rheumatic  diathesis  occasionally 
plays  a  part  as  an  etiological  factor.  In 
such  cases  the  ammoniated  tincture  of 
guaiac,  1  drachm  in  milk  three  times  a 
day,  or  the  tincture  of  colchicum-root, 
10  drops  every  three  hours  vmtil  the 
bowels  become  free,  will  sometimes  re- 
store arrested  menstruation.  The  salic- 
ylate of  sodium  is  also  valuable  in  this 
connection.  Apiol,  4  grains  daily  in 
l-grain  pills,  for  fifteen  days,  has  given 
good  results. 

Apiolin  is  best  combined  with  iron. 
Iron  should  be  given  uninteiTuptedly 
until  a  few  days  before  the  expected  ap- 
pearance of  the  menses.  Then^  continu- 
ing the  iron,  apiolin  should  be  prescribed 
in  5-minim  doses  three  times  daily  until 
the  appearance  of  the  menstrual  flow. 
W.  A.  Newman  Borland  (Amer.  Thera- 
pist, July,  '92). 

Eumencl,  an  extract  made  from  the 
root  of  a  plant  called  tang-kui,  a  Chinese 
remedy  which  contains  nothing  poison- 
ous or  capable  of  producing  abortion, 
tried  in  14  eases.  In  two  of  these  there 
was  no  appreciable  result.  In  all  the 
others,  although  the  medication  was  com- 
bined with  hydrotherapy,  massage,  and 
the  administration  of  iron.  The  good 
effect  of  the  drug  appreciable.  Acting 
as  a  general  tonic,  it  brought  on  the  flow 


at  the  correct  period,  besides  increasing 
it    and    making    less    sever3    the    pre- 
menstrual pain.     The  refined  extract  as 
prepared    by   Merck    is   called    eumenol. 
Hirth  (Munch,  med.  Woch.,  June  6,  '99). 
Electricity  is  of  great  value,  faradism, 
static  electricity,  galvanism,  and  galvanic 
intra-uterine   pessaries  being  applicable 
according  to  the  nature  of  the  case. 

Besides  general  treatment,  percutane- 
ous electrical  application,  viz.:  spinal 
and  combined  spinal  and  abdominal  ap- 
plications of  the  galvanic  current.  In 
the  former  the  anode  is  applied  im- 
movably over  the  lumbar  region,  while 
stabile  application  of  the  cathode  is  made 
over  cei-v'ical  and  dorsal  regions  for  the 
space  of  one  minute,  the  dose  being  10 
to  15  milliamperes;  in  the  latter  the 
anode  is  applied  as  before,  and  the  ca- 
thode over  each  ovarian  region,  for  fiftetn 
to  thirty  minutes. 

In  case  of  retarded  development  the 
faradic  current  is  used,  the  anode  over 
the  back  and  hypogastric  region;  the 
cathode,  a  well-insulated  sound,  is  intro- 
duced into  the  uterus.  The  duration  of 
the  sitting  is  five  to  ten  minutes,  dose 
5  to  25  milliamperes.  In  some  cases 
Apostoli's  bipolar  electrode  is  best  used 
when  an  electrolytic  action  on  the  mu- 
cous membrane  is  sought  for.  In  the 
majority  of  cases  the  ovaries  must  be 
included  in  the  treatment  by  a  cup- 
shaped  electrode  to  cervix  (cathode) 
while  the  anode  is  placed  over  each 
OA"arian  region ;  the  dose  is  10  to  60 
milliamperes  for  three  minutes  eveiy 
third  day.  H.  N.  Hinton  (Occidental 
Med.  Times,  '90). 

Series  of  cases  treated  by  negative 
intra-uterine  electrization,  with  currents 
of  30  to  40  milliamperes,  for  five  minutes, 
the  applications  to  be  made  about  the 
time  the  menses  are  expected.  These 
applications  act  by  a  complex  action 
upon  the  uterus  and  ovaries,  causing 
great  congestion,  and  upon  the  nervous 
plexus  presiding  over  the  ovarian  func- 
tions. 

It  should  be  reserved  for  cases  in 
which  amenorrhcea  is  only  transitory, 
depending  either  upon  some  fault  of 
vitality  in  the  ovary  (obesity,  premature 


260 


AMENORRHCEA. 


AMMONIA. 


menopause,  retarded  menstruation  in 
young  girls  near  the  age  of  puberty)  or 
upon  a  lesion  of  the  ovaries  (chronic 
sclerocystic  ovaritis)  or  of  the  uterus 
(chronic  interstitial  metritis,  destruction 
of  the  mucous  membrane  by  chloride  of 
zinc;  or  by  curetting,  with  or  without 
Schroder's  operation). 

It  is  eonti-a-indicated  in  cases  of  physi- 
ological amenorrhoea  dependent  on  preg- 
nancy, the  menopause,  or  lactation. 

It  is  useless  in  cases  following  a  severe 
disease  of  which  it  is  but  a  symptom 
or  sequel  ( chloransemia,  morphinomania, 
tuberculosis). 

It  constitutes  the  most  efficacious 
treatment  known  for  amenorrhoea  not 
dependent  upon  an  organic  irremediable 
cause.  Nitot  (Jour,  de  Med.,  June  26, 
'92). 

[We  can  only  approve,  in  confirming 
it,  of  the  author's  conclusions.  In  rebell- 
ious cases  the  action  of  galvanic  currents 
may  sometimes  be  powerfully  aided  and 
completed  by  sinusoidal  cun-ents,  which 
favor  the  flow  of  blood,  either  during 
the  menstrual  period  or  outside  of  it. 
Apostoli  and  Grand,  Assoc.  Eds.,  An- 
nual, '93.] 

Extract  of  cows'  ovaries  has  been  used 
with  success,  but  further  trials  with  this 
agent  are  required  to  establish  its  actual 
value. 

Experiments  with  three  fresh  eow- 
ovaiy  preparation  (Merck's) ;  the  entire 
ovary,  the  canals,  and  a  precipitate  of 
the  contents  of  the  follicle-contents.  The 
remedies  were  administered  in  form  af 
tablet  containing  4  grains  each  of  the 
ovary  preparation  and  common  salt. 
The  results  obtained  in  eleven  cases  do 
not  warrant  any  positive  conclusion, 
although  encouraging  as  to  future  trials. 
R.  Mond  (Miinchener  med.  Woch.,  xliii. 
No.  14,  '96). 

Ovarian  treatment,  administered  under 
the  form  of  dried  powder  of  the  ovaries 
of  heifers,  in  the  dose  of  4  or  5  grains 
daily,  is  not  dangerous.  In  order  to 
act  it  should  be  continued  for  some 
months;  it  is  indicated  in  amenorrhoea, 
chloransemia,  artificial  menopause  due  to 
removal  of  the  genital  organs,  and  acci- 
dents   of    the    normal    menopause.      L. 


Touvenaint    (Revue    des    Sci.    Med.    en 
France  et  a,  I'Etranger,  Jan.  15,  '96). 

Extract  of  ovaries  found  especially 
valuable  in  amenorrhoea  attending  chlo- 
rosis among  a  large  number  of  cases  in 
which  it  was  tried.  Muret  (Revue  Med. 
de  la  Suisse  Rom.,  July,  '97). 

E.  E.  Montgomery, 

Philadelphia. 

AMMONIA. — Ammonia  is  a  transpar- 
ent, colorless  gas  very  acrid  to  the  taste 
and  giving  a  markedly  alkaline  reaction. 
It  is  made,  in  large  quantities,  from  coal- 
gas,  by  heating  the  ammoniacal  liquor 
with  calcium  hydrate,  then  conducting 
the  gas  through  tubes  containing  char- 
coal. It  may  also  be  obtained  by  heating 
a  mixture  of  dry  slaked  lime  with  chlo- 
ride of  ammonium.  It  evaporates  with 
exceeding  rapidity.  It  is  very  soluble  in 
water. 

Dose  and  Preparations. — The  prepara- 
tion used  in  medicine  is  a  strong  solu- 
tion, or  water  of  ammonia,  the  aqua 
ammonise  fortior,  U.  S.  P.,  which  con- 
tains 28  per  cent.,  by  weiglit,  of  gas;  it 
is  used  mainly  as  a  vesicant.  A  weaker 
solution  (hartshorn),  the  aqua  ammoniae, 
U.  S.  P.,  is  more  generally  employed, 
and  contains  10  per  cent,  of  the  gas  by 
weight. 

Liniment  of  ammonia:  composed  of 
water  of  ammonia,  30  parts;  cottonseed- 
oil,  70  parts. 

Camphorated  liniment  of  ammonia: 
composed  of  water  of  ammonia,  30  parts; 
camphor-liniment,  70  parts. 

Aromatic  spirit  of  ammonia:  composed 
of  carbonate  of  ammonia,  40  parts;  water 
of  ammonia,  100  parts;  oil  of  lemon,  12 
parts;  oil  of  lavender-flowers,  1  part;  al- 
cohol, 700  parts;  water  enough  to  make 
1000  parts.    Dose,  30  to  60  minims. 

Spirit  of  ammonia:  an  alcoholic,  col- 
orless solution  containing  10  per  cent.. 


AMMONIA.     PHYSIOLOGICAL  ACTION.    POISONING.    THERAPEUTICS.        201 


by  weight,  of  the  gas.     Dose,  10  to  30 
minims. 

Fcetid  spirit  of  ammonia:  composed  of 
1  part  of  asafoetida  to  21  parts  of  spirit 
of  ammonia.    Dose,  ^/^  drachm. 

Ointment  of  ammonia:  composed  of 
17  parts  of  water  of  ammonia,  32  parts  of 
lard,  and  2  parts  of  oil  of  sweet  almonds. 
Physiological  Action. — Ammonia  is  a 
most  powerfiil  irritant  to  the  tissues;  if 
the  exposure  be  long,  local  death  and 
sloughing  ensue.  Inhaled  it  may  also 
produce  rapid  death  by  oedema  of  the 
glottis  or  spasm.  Moderate  inhalations 
cause  bronchitis,  or  at  least  tracheitis. 
Upon  the  nervous  system  it  acts  as  a 
spinal  excitant,  increasing  reflex  action 
and  spinal  activity.  Applied  directly  to 
a  nerve,  either  motor  or  sensory,  it  par- 
alyzes it;  in  very  weak  solution  it  seems 
to  increase  its  functional  activity.  The 
circulation  is  increased  to  a  great  extent: 
the  pulse-rate,  pulse-force,  and  arterial 
pressure  being  due  to  stimulation  of  the 
accelerator  nerves  of  the  heart.  The 
force  of  the  action  of  the  ventricles  is 
much  increased,  and  this,  in  turn,  in- 
creases arterial  pressure.  In  moderate 
amounts  ammonia  does  not  change  the 
blood,  but  in  poisonous  quantities  it 
causes  it  to  cease  absorbing  oxygen.  The 
rate  of  respiration  is  increased  by  stim- 
ulation of  the  respiratory  centre;  the 
respiratory  movements  become  not  only 
more  full,  but  more  rapid.  Inhaled  in 
small  amounts,  it  causes  the  same  action 
to  a  smaller  degree.  When  large  amounts 
are  taken,  ammonia  is  eliminated  by  the 
breath,  is  burnt  up  in  the  system,  and  is 
excreted  in  the  urine. 

Special  research  showing  that  the  elim- 
ination of  this  gas  by  the  lungs  is  doubt- 
ful. Paul  Binet  (Revue  M6d.  de  la  Suisse 
Rom.,  .June  20,  July  20,  '93). 

Ammonia  exercises  a  depressing  action 
on  the  liver,  producing  an  increase  in  the 
amount  of  iron  and  a  diminution  in  gly- 


cogen. T.  Lauder  Brunton  and  S.  Dele- 
pine  (Proceedings  of  the  Royal  Soc,  No. 
334,  '94). 

Ammonia  Poisoning. — -True  poisonous 
effects  are  rarely  observed,  the  intense 
caustic  action  of  ammonia  upon  the 
mucous  membranes  of  the  mouth  and 
throat  causing  the  liquid  to  be  coughed 
out  almost  immediately  in  the  majority 
of  instances.  Spasm  of  the  glottis  and 
oedema  may  cause  death.  If  the  liquid 
is  swallowed  the  mucous  layer  of  the 
oesophagus  becomes  acutely  inflamed, 
softened,  and  itlcerated,  and  stricture  of 
the  oesophagus  usually  follows. 

Treatment  of  Ammonia  Poisoning.  — 
The  antidotes  are  vinegar  and  lime-juice. 
Bland  liquids — such  as  oil  or  milk — - 
should  be  given,  and  stimulants — such 
as  strong  coffee — should  be  administered 
by  rectal  injection  if  the  patient  is  un- 
able to  swallow.  Hypodermic  injections 
of  ether  or  digitalis  are  valuable  to  sus- 
tain cardiac  action  if  there  is  marked 
depression  or  shock. 

Therapeutics. — Asphyxia,  Collapse, 
AND  Shoce. — In  asphyxia,  whatever  be 
its  origin,  ammonia  is  a  valuable  agent, 
taken  internally  and  simultaneously  in- 
haled. During  the  latter  procedure,  how- 
ever, care  should  be  taken  to  not  spill 
the  liquid  into  the  mouth  or  nose  of  the 
patient,  which  is  likely  to  occur  when  he 
is  in  the  recumbent  position.  Serious  in- 
jury has  followed  accidents  of  this  kind. 
In  collapse  and  heart-failure,  from  10 
minims  to  a  drachm  of  the  water  of  am- 
monia, mixed  with  6  drachms  of  sterilized 
water,  may  be  injected  into  a  vein. 

Hypodermic  injection  of  aromatic 
spirit  of  ammonia  valuable  in  asphyxia 
and  allied  conditions.  Case  of  ursemic 
convulsions  following  scarlet  fever,  in 
which  respiration  and  pulsation  had 
apparently  ceased;  the  injection  of  1 
drachm  above  the  cardiac  region  caused 
the   patient   to   return    to   consciousness 


262 


AMMONIA. 


AMMONIUM. 


four  consecutive  times.  Then  used  in 
other  eases,  including  one  of  gas  poison- 
ing. The  aromatic  spirit  of  ammonia 
should  always  be  diluted  in  order  to  pre- 
vent sloughing  of  the  tissues  in  the 
vicinity  of  the  injection.  A.  J.  C.  Saunier 
(St.  Thomas's  Hosp.  Reports,  London, 
June  1,  '94). 

'  In  infants,  the  stage  of  collapse  occur- 
ring in  summer  diarrhcea  may  also  he 
counteracted  with  a  few  drops  of  ammo- 
nia occasionally  administered. 

In  extreme  stupor  Fischer  sometimes 
gives  3  drops  of  aromatic  spirit  of  am- 
monia, with  10  drops  of  water.  (Post- 
graduate, Sept.,  '92). 

Gasthic  Hyperacidity. — In  this  con- 
dition, characterized  by  "heart-burn," 
acid  eructations,  and  in  fermentative 
processes  following  the  ingestion  of  cer- 
tain kinds  of  food,  a  few  drops  (3  to 
5)  of  water  of  ammonia  or  10  drops  of 
the  aromatic  spirit  in  a  little  water  fre- 
quently afford  prompt  relief.  The  fact 
noted  by  Sir  Benjamin  Ward  Eichardson 
that  ammonia  was  antiseptic  probably 
accounts,  in  a  measure,  for  its  effective- 
ness in  arresting  fermentative  processes. 

Alcoholism. — In  acute  alcoholic  in- 
toxication the  various  preparations  of 
ammonia  are  considerably  used.  (See 
Alcoholism.)  Lavage  of  the  stomach, 
followed  by  10  drops  of  water  of  am- 
monia in  a  half-tumblerful  of  water, 
promptly  counteracts  the  effects  of  in- 
toxication. 

Cholera.  —  For  the  algid  stage,  am- 
monia internally  and  ether  hypodermic- 
ally,  besides  the  free  administration  of 
alcohol,  have  been  highly  recommended 
by  Giacich,  the  aim  being  to  support  the 
failing  heart.  Marked  improvement  in 
the  general  condition  was  noted  within 
two  hours  after  the  institution  of  this 
mode  of  treatment,  and  over  50  per  cent, 
of  those  who  had  reached  the  algid  stage 
are  said  to  have  been  saved.     Dumont- 


pallier  also  recommends  for  the  same 
purpose  the  hydrochlorate  of  ammonium. 
Besides  the  return  of  heat  and  perspi- 
ration caused  by  this  salt,  it  increases 
diuresis,  and  therefore  increases  the 
elimination  of  the  toxic  elements  of  the 
disease. 

Stings  of  Insects,  Snake-bites,  etc. 
— In  lesions  produced  by  venomous  rep- 
tiles and  insects,  and  carnivorous  ani- 
mals the  antiseptic  and  corrosive  effects 
of  ammonia  can  be  utilized  to  great  ad- 
vantage. The  best  plan  in  snake-bites 
is  to  apply  it  directly  to  the  wound  and 
to  inject  into  a  vein  a  solution  of  30  to 
60  minims  in  6  drachms  of  water.  The 
pure  ammonia-water  applied  over  the 
bites  or  stings  of  insects  is  effective;  it 
reduces  markedly  the  pruritus  and  pain. 

Rheumatism.  —  The  liniment  some- 
times quickly  relieves  mild  forms  of 
rheumatism  and  lumbago.  When  the 
skin  is  delicate,  as  it  is  in  women,  it 
acts  as  an  active  rubefacient. 

AMMONIUM.— When  an  acid  gas  and 
ammonia-gas  are  brought  together  with- 
out liberation  of  hydrogen,  a  compound 
of  ammonium  is  formed,  which  varies 
with  the  acid  radicle  forming  the  basis 
of  the  combination.  We  thus  have 
formed  the  following  salts: — • 

Ammonium  arseniate,  dose,  Veo  to  ^/as 
grain. 

Ammonium  benzoate,  dose,  10  to  30 
grains. 

Ammonium  bicarbonate,  dose,  10  to 
60  grains. 

Ammonium  borate,  dose,  10  to  20 
grains. 

Ammonium  bromide,  dose,  10  to  60 
grains. 

Ammonium  carbonate,  dose,  2  to  10 
grains. 

Ammonium   chloride,    dose,    5   to    30 


AMMONIUM  CARBONATE. 


263 


Ammonium  fluoride,  dose,  Vioo  to  V25 
grain. 

Ammonium  formate,  dose,  1  to  5 
grains. 

Ammonium  iodide,  dose,  3  to  5  grains. 

Ammonium  nitrate  (employed  in  the 
manufactures). 

Ammonium  nitrite,  dose,  20  to  40 
grains. 

Ammonium  phosphate,  dose,  10  to  20 
grains. 

Ammonium  picrate,  dose,  ^/o  to  1 
grain. 

Ammonium  salicylate,  dose,  10  to  40 
grains. 

Ammonium  siilphate  (employed  in  the 
manufacture  of  aqua  ammonise). 

Ammonium  sulphite,  dose,  20  to  60 
grains. 

Ammonium  valerianate,  dose,  2  to  10 
grains. 

Physiological  Action.  —  Some  of  the 
salts  of  ammonium  stimulate  the  spinal 
cord  and  have  no  marked  paralyzing 
influence  npon  the  motor  nerves,  while 
others  have  no  distinct  stimulating  ac- 
tion on  the  cord,  and  paralyze  both  it 
and  the  motor  nerves.  Many  ammonium 
salts  stimulate  the  vasomotor  centres. 
These  varied  actions  are  mainly  due  to 
the  acid  radicle  entering  into  the  com- 
bination of  the  majority  of  ammonium 
salts.  These,  including  the  arseniate,  the 
benzoate,  the  picrate,  etc.,  will  be  treated 
under  the  headings  including  their  acid 
radicle:  Aesenic,  Benzoic  Acid,  Picric 
Acid,  etc.  Others  owe  their  properties 
mainly  to  the  ammonium  acting  as  base. 
The  most  important  of  these  will  be 
treated  of  in  the  following  sections. 

Ammonium  Acetate. 

The  ammonium  acetate  is  seldom  used 
in  its  natural  state;  but  it  enters  into 
the  preparation  of  spirit  of  Mindererus 
(liqiTor  ammonii  acetatis),  which,  in  turn, 
is  extensively  employed.  This  is  prepared 


by  saturating  dilute  acetic  acid  with  am- 
monium carbonate.  This  forms  a  color- 
less liquid,  which  gives  ofE  a  very  faint 
odor  of  acetic  acid.  It  has  an  unpleasant 
saline  taste. 

Dose.  —  The  dose  of  spirit  of  Minde- 
rerus is  1  drachm  to  2  tablespoonfuls, 
repeated  every  two  or  three  hours. 

Physiological  Action.  — •  Although  the 
general  use  which  this  preparation  enjoys 
indicates  that  it  possesses  some  active 
virtues,  all  that  can  be  said  of  it  is  that 
it  is  a  weak  stimulating  diaphoretic  pos- 
sessing also  diuretic  properties.  The 
latter  it  exerts  without  irritating  the 
kidneys,  increasing  both  the  quantity  of 
fluid  and  the  excretion  of  solids. 

In  the  light  of  our  present  knowledge, 
however,  the  properties  just  mentioned 
would  seem  to  fulfill  precisely  the  con- 
ditions desirable  for  the  elimination  of 
toxic  products,  in  which  process  the  skin 
and  the  kidneys  play  so  prominent  a 
part. 

Therapeutics.  —  It  is  especially  used 
at  the  outset  of  adynamic  fevers  and, 
in  fact,  should  only  be  used  during  this 
period  of  any  disease,  before  the  stage  of 
depression  is  near.  Sweet  spirit  of  nitre 
is  generally  preferred,  owing  to  its  more 
agreeable  taste.  It  affords  relief  in  some 
cases  of  dyspepsia  as  an  antacid. 

Ammonium  Carbonate. 

Ammonium  carbonate  is  prepared  by 
heating  a  mixture  of  ammonium  chloride 
and  calcium  carbonate,  then  condensing 
the  product.  It  occurs  in  white  translu- 
cent masses,  which,  on  exposure,  become 
opaque  and  friable,  owing  to  the  fact 
that  it  parts  with  its  ammonia  and  passes 
from  a  sesqui-  into  a  hi-  carbonate.  It 
has  a  pungent  odor,  a  sharp  taste,  and 
an  acid  reaction.  It  is  soluble  in  four 
and  a  half  times  its  weight  of  water. 

Dose.  —  The  dose  of  ammonium  car- 
bonate  is  from   5  to   10  grains,  which 


364 


AMMOXIUil  CHLORIDE. 


should  be  repeated  in  two  hours  at  the 
longest,  the  effect  of  the  drug  being 
evanescent. 

Physiological  Action.  —  Ammonium 
carbonate  possesses  to  a  smaller  degree 
the  stimulating  properties  of  ammonia. 
It  excites  the  functions  of  the  skin,  the 
kidneys,  the  bronchial  glands,  and  the 
epithelium.  It  reduces  the  normal  gas- 
tric acidity  and  tends  to  irritate  the 
stomach  and  cause  vomiting  if  given  in 
too  large  doses.  It  is  thought  to  play 
an  important  role  in  the  formation  of 
urea  and  glycogen  when  penetrating  the 
liver  with  a  carbohydrate,  the  adminis- 
tration of  food  with  ammonium  salts 
being  known  to  encourage  the  excretion 
of  urea.  Carbonate  of  ammonia  also 
possesses  antiseptic  properties. 

A  5-  to  8-per-eent.  ammonium  solution 
will  preserve  rabbit-fat  ten  months  from 
decomposition.  A  5-per-cent.  solution  of 
ammonium  carbonate  also  acts  as  an 
antiseptic.  Meat,  animal  organs,  etc., 
kept  in  fumes  of  this  drug,  look  nearly 
the  same  after  six  months.  C.  Gott- 
brecht  (Arehiv  fur  exp.  Path,  und 
Pharm.,  B.  25,  H.  5,  6,  "90). 

Therapeutics, — This  drug  is  especially 
valuable  in  diseases  of  the  respiratory 
tract.  It  acts  as  an  active  expectorant. 
In  bronchitis,  especially  in  the  chronic 
form,  when  the  dyspncea  is  marked  and 
the  general  adynamia  is  caused  by  inter- 
ference with  the  functions  of  the  pitl- 
monary  tract,  it  probably  represents  the 
best  agent  at  our  command.  H.  C.  "Wood 
regards  it  as  the  best  preparation  for 
continuous  use  in  typhoid  pneumonia. 
In  both  of  the  diseases  mentioned  it  may 
be  given  in  doses  of  from  5  to  10  grains, 
repeated  every  two  hours,  the  effects  of 
this  dose  upon  the  system  lasting  no 
longer  than  that  time. 

It  is  a  valuable  drug  as  a  cardiac  and 
nervous  stimulant  in  the  capillary  bron- 


chitis —  broncho-pneumonia  —  of    chil- 
dren. 

In  acute  coryza  it  is  also  employed 
with  satisfactory  results. 

The  best  means  of  aborting  an  attack 
of  acute  coryza  is  the  administration  of 
rather  large  and  frequently-repeated 
doses  of  carbonate  of  ammonia.  Beverly 
Eobinson  (Boston  Med.  and  Surg.  Jour., 
Nov.  14,  '89). 

Ammonium  Chloride. 

Chloride  of  ammonium — or,  as  it  used 
to  be  preferably  called,  muriate  of  am- 
monia, or  "sal  ammoniac" — is  a  white, 
translucent  salt,  having  no  odor,  but  a 
sharp,  saline  taste.  It  dissolves  in  three 
parts  of  cold  and  in  one  part  of  boiling 
water,  and  sublimes  without  decomposi- 
tion at  red  heat. 

Dose.  —  The  usual  dose  is  5  to  10 
grains,  but  when  a  sudden  effect  is  to  be 
produced,  as  in  alcoholism,  from  30  to 
60  grains  may  be  administered,  with  a 
copious  draught  of  water. 

Physiological  Action. — Applied  in  its 
solid  form  or  in  saturated  solution,  am- 
monium chloride  acts  as  an  irritant  upon 
mucous  membranes.  When  given  con- 
tinuously for  some  time,  it  is  thought  to 
produce  a  profound  impression  upon  the 
blood  itself,  lessening  its  plasticity  and 
impairing  its  constitution;  it  may  then 
cause  prostration  accompanied  by  the 
extravasation  of  blood  under  the  skin, 
hsematuria,  and  hfemorrhages  from  the 
mucous  membranes.  In  smaller  doses 
long  continued  it  tends  to  impoverish 
the  blood,  the  latter  containing  less  than 
the  normal  percentage  of  solids.  It  in- 
creases very  notably  all  the  solids  of  the 
urine,  except  the  uric  acid.  It  affects 
the  mucous  membranes,  encouraging  nu- 
tritive changes  and  the  exfoliation  of 
epithelium.  Its  chief  elimination  takes 
place  through  the  kidneys. 

Ammonium-Chloride  Poisoning. — The 


AMMONIUM  CHLORIDE.     THERAPEUTICS. 


265 


experimental  evidence  published  is  con- 
tradictory, but  it  tends  to  show  that  this 
salt  does  not  possess  much  toxic  power 
even  in  large  doses. 

Gourinsky,  after  some  experiments  on 
frogs  and  pigeons  poisoned  with  am- 
monium chloride,  reached  the  following 
conclusions:  In  frogs  whose  spinal  cord 
has  been  divided  below  the  medulla 
oblongata,  ammonium  chloride  produces 
from  the  first  a  marked  augmentation 
of  reflex  acts.  In  frogs  deprived  of  cer- 
tain parts  of  the  central  nervous  system 
(spinal  cord,  medulla  oblongata,  the 
cerebellum  alone  being  retained)  this 
augmentation  is  preceded  by  a  marked 
depression.  In  normal  frogs  and  pigeons 
chloride  of  ammonium  produces  at  first 
depression  of  the  central  nervous  system, 
then  convulsions:  that  is,  the  higher 
centres  exercise  a  great  inhibitory  influ- 
ence on  the  spinal  reflexes.  'V\Tien  the 
poison  is  introduced  rapidly  the  flrst 
stage  (that  of  depression)  is  but  slightly 
marked,  and  soon  gives  place  to  the 
second  stage  (that  of  irritation,  ushered 
in  by  convulsions).  When  the  poison  is 
introduced  slowly  the  general  nervous 
depression  is  well  marked  and  lasts  a 
long  time.  In  frogs  and  pigeons  de- 
prived of  the  cerebral  hemispheres  onl}', 
whatever  be  the  method  of  introducing 
the  poison,  convulsions  are  not  preceded 
by  depression,  but  the  latter  is  sometimes 
replaced  by  irritability.  All  the  facts 
can  be  explained  only  by  the  reciprocal 
action  of  the  nervous  centres  on  each 
other,  modified  by  the  poison. 

In  a  case  in  which  a  large  quantity  of 
ammonium  hydrate  had  been  talven  the 
mucous  membrane  of  the  anterior  part 
of  the  mouth  was  denuded,  and  the 
peculiar  fact  was  noted  that  after  three 
days,  when  solid  nourishment  was  again 
taken,  the  food  appeared  to  be  saltless. 
P.  Carles  (Jour,  de  Med.  de  Bordeaux, 
.July  13,  '90). 


Therapeutics.  —  Ammonium  chloride 
is  especially  valuable  in  all  disorders  in 
which  the  mucous  membrane  is  involved. 

Gasteic  Cataeeh  and  Hepatic 
ToEPOE. — That  ammonium  chloride  is 
valuable  in  catarrhal  disorders  of  the 
stomach,  especially  in  children,  is  sus- 
tained by  the  frequency  with  which  it 
is  still  resorted  to.  It  may  be  given  in 
compressed  pills,  but  a  half-tumblerful 
of  pure  water  should  be  taken  simulta- 
neously to  prevent  the  irritating  action 
of  the  salt  itself  upon  the  gastric  mucous 
membrane.  Milk  may  be  used  instead  of 
water. 

In  all  conditions  characterized  by 
torpidity  of  the  liver,  whether  due  to 
subacute  hepatitis  or  general  asthenia, 
chloride  of  ammonium  is  very  valuable, 
in  doses  of  20  grains  three  times  a  day. 

In  doses  of  I  Vi  drachms  per  day  it 
enhances  the  assimilation  of  fattj'  arti- 
cles of  food,  increases  the  diuresis,  and 
diminishes  the  body-weight.  W.  V.  Mali- 
nine   (These  de  St.  Petersbourg,  '93). 

In  dailj'  doses  of  75  grains  chloride  of 
ammonium  increases  the  assimilation  of 
nitrogenous  food.  The  elimination  of 
improperly-oxidized  products  of  neutral 
sulphur  and  of  nitrogenous  waste  is 
augmented.  It  diminishes  the  number 
of  the  stools,  but  increases  the  absolute 
quantity  of  urine  and  the  urinary  salts. 
The  reaction  of  the  urine  remains  acid, 
but  its  specific  gravity  is  diminished. 
V.  S.  Tchernycheff  (These  de  St.  Peters- 
bourg, '93). 

Ammonium  chloride  acts  as  a  stimu- 
lant to  the  liver,  causing  at  the  same 
time  a  slight  diminution  in  the  amount 
of  free  iron  in  the  organ.  T.  L.  Brunton 
and  S.  Delepine  (Proceedings  of  the 
Royal  Soc.,  No.  334,  '94). 

Encouraging  results  from  the  use  of 
ammonium  chloride  in  dj'sentery.  Sixty 
grains  may  be  given  every  four  hours; 
this  rapidly  decreases  the  amount  of 
blood  and  the  severity  of  the  pain.  J. 
W.  S.  Attygalle  (Brit.  Med.  Jour.,  Jan. 
29,  '98). 


266 


AMMONIUM  CHLORIDE.    THERAPEUTICS. 


DiSOHDERS  OF  THE  EeSPIEATOET 

Teact. — •Ammonium  chloride  lias  long 
been  used  as  an  effective  remedy  in  al- 
most every  disorder  of  the  respiratory 
tract.  In  recent  years,  however,  the  car- 
bonate has  replaced  the  chloride  in  the 
treatment  of  pulmonary  disorders,  but 
the  chloride  is  still  considerably  used  in 
chronic  bronchitis. 

The  fumes  generated  by  the  action 
of  hydrochloric  acid  upon  ammonia  are 
considerably  used  as  inhalents  and  are 
quite  effective  in  mild  chronic  disorders. 

Nascent  ammonium  chloride  may  be 
used  to  advantage  in  pneumonia.  It 
may  be  generated  by  shaking  together 
two  cloths,  the  one  wet  with  strong  am- 
monia and  the  other  with  commercial 
hydrochloric  acid.  The  nascent  am- 
monium chloride  is  suspended  like  smoke 
in  the  room^  and  is  inhaled  by  the  pa- 
tient. This  substance  is  a  germicide,  the 
free  ammonia  is  a  tonic  and  stimulant 
to  the  lungs,  and  the  acid  supplies  the 
deficiency  of  chloride.  This  method  does 
not  disturb  the  patient.  T.  Ashburton 
(Albany  Med.  Annals,  No.  7,  p.  360,  '97). 

The  value  of  chloride-of-ammonium 
troches  as  a  stimulant  for  pharyngeal 
disorders  is  well  known.  It  serves  the 
double  purpose  of  increasing  local  lubri- 
cation by  stimulating  the  acini,  and  of 
gently  enhancing  hepatic  action.  It  may 
also  be  used  in  the  form  of  spray. 

Ammonium  chloride  in  the  form  of  a 
spray  is  valuable  in  the  various  catarrhs 
of  the  respiratory  tract.  Krakauer 
(Centralb.  f.  klin.  Med.,  Oct.  15,  '89). 

Middle-Eae  Disoedees.  —  The  use 
of  ehloride-of-ammonium  vapor  in  af- 
fections of  the  middle  ear  has  been 
prompted  by  its  effectiveness  in  the 
treatment  of  catarrhal  affections  of  the 
nasal  mucous  membrane,  with  which 
many  aural  disorders  are  intimately  con- 
nected. 

Chloride-of-ammonium  vapor  may  be 
generated    by    attaching    a    Richardson 


continuous-spray  apparatus,  by  the  prox- 
imal end  of  the  elastic  ball  to  the  dis- 
tributing-tube of  a  Vereker  chloride-of- 
ammonium  inhaler,  and  a  Eustachian 
catheter  to  the  distributing-end  of  the 
spray-apparatus.  A  few  squeezes  must 
first  be  given  to  the  ball  so  as  to  fill  the 
apparatus  with  gas  before  introducing 
the  catheter. 

Again,  if  such  a  catheter,  or  even  a 
glass  tube  drawn  to  a  point,  be  affixed 
to  a  Higginson  syringe,  one  of  the  best 
and  handiest  means  of  syringing  the  ex- 
ternal ear  will  be  afforded.  The  small 
and  practically  continuous  jet,  applied 
with  any  force  desirable,  almost  imme- 
diately tunnels  a  hole  in  the  hardest 
cerumen  and  quickly  allows  of  that 
reflex  current  necessary  for  its  removal, 
doing  away  with  the  need  for  clumsy  ear- 
syringes.  J.  MacMunn  (Brit.  Med.  Jour., 
Oct.  19,  '95). 

Cystitis. — In  catarrhal  inflammation 
of  the  bladder  chloride  of  ammonium 
sometimes  proves  very  effective,  espe- 
cially if  taken  with  a  tumblerful  of 
water.  Ten  grains  every  four  hours  the 
first  day  and  5  grains  the  second  day  and 
thereafter  soon  cause  the  local  distress 
to  at  least  greatly  diminish. 

Ammonium  chloride  valuable  in  cys- 
titis, primary  or  secondary.  A  capsule 
containing  5  grains  of  pulverized  purified 
drug  should  be  taken  three  of  four  times 
in  twenty-four  hours,  preferably  when 
the  stomach  is  empty,  and  followed  im- 
mediately by  a  half-gobletful  or  a  goblet- 
ful  of  pure  cold  water.  Faithfully  tried 
in  a  large  number  of  varied  conditions 
with  most  satisfactory  results.  In  the 
majority  of  cases  the  urine  was  rapidly 
cleared  of  mucus,  blood-corpuscles,  pus- 
corpuscles,  urates,  and  phosphates,  and 
the  distressing  symptoms  speedily  disap- 
peared. Corrie  (Virginia  Med.  Monthly, 
vol.  XX,  No.  6,  '93). 

Alcoholism.  —  In.  alcoholic  intoxica- 
tion the  chloride  of  ammonium  acts  as 
effectively  as  ammonia.  Its  beneficial 
infiuence  upon  the  liver  renders  it  pref- 
erable to  the  latter.     Thirty  grains,  re- 


AMMONIUM. 


AMYLENE. 


267 


peated  in  thirty  minutes,  effectively 
brings  the  sufferer  to  his  normal  con- 
dition, as  far  as  the  mental  aberration 
is  concerned.  This  action  will  be  con- 
tinuous if  an  emetic  or  lavage  of  the 
stomach  have  previously  been  resorted 
to. 

Case  of  delirium  tremens  in  wliich  1 
grain  of  morpliine  hypodermically  did 
not  produce  tlie  slightest  effect.  After 
the  symptoms  had  all  become  aggra- 
vated, 1  drachm  of  chloride  of  ammonium 
given.  This  was  promptly  vomited. 
After  a  short  time  another  drachm  given, 
which  was  retained.  In  fifteen  minutes 
the  hallucinations — snakes,  etc. — disap- 
peared, and  the  patient  became  quite 
rational.  In  forty  minutes  he  was  asleep 
Gilbert  G.  Cottam  (Medicine,  Nov.,  '96) 
Case  of  a  woman  who  had  been  in 
toxicated  for  eight  days.  She  had  "rep 
tile"  hallucinations,  etc.  Chloride  of  am 
monium,  '/,  drachm  in  a  large  quantity 
of  water,  taken  in  two  gulps.  In  fifteen 
minutes  she  was  quieter;  in  fifteen  min- 
utes more  the  other  half-drachm  was 
-  given.  In  a  short  time  she  was  asleep. 
W.  B.  Gossett  (N.  Y.  Med.  Jour.,  .Jan. 
23,  '97). 

Neuealgia  and  Migraine. — In  these 
disorders  ammonium  chloride  frequently 
gives  considerable  relief,  especially  if 
given  with  tincture  of  aconite.  Twenty 
grains  of  ammonium  chloride  with  2 
minims  of  the  tincture  used  every  half- 
hour  three  times  usually  procures  con- 
siderable diminution  of  the  suffering. 

Chloride  of  ammonium  in  supra-orbital 
neuralgia  relieves  the  pain  at  once.  It 
should  be  administered  internally,  and 
a  small  amount  of  it,  finely  powdered, 
be  drawn,  into  the  nostril  of  the  affected 
side.  Chetan  Shah  Naug  (Indian  M  d. 
Gaz.,  Apr.,  '88). 

Good  results  obtained  from  doses  of 
20  grains  in  obstinate  neuralgia.  Green 
(Med.  Press  and  Circular,  Sept.  22,  '88). 

Wounds. — In  the  treatment  of  wounds 
its  antiseptic  qualities  have  been  empha- 
sized by  H.   C.   Wyman,   who   obtained 


good  results  from  an  antiseptic  gauze 
steeped  in  an  ammonium-chloride  solu- 
tion, 1  ounce  to  V,  pint  of  water,  espe- 
cially in  contused  wounds.  The  circu- 
lation of  the  blood  is  increased  in  the 
parts  which  have  been  deprived  of  the 
wholesome  influence  of  the  blood-current. 

AMYL-HYDEILE.     See  Pentane. 

AMYLENE  is  a  derivative  of  fermen- 
tation of  amyl-alcohol,  which  in  the  pure 
state  has  an  oily  character  and  an  odor 
resembling  that  of  old  whisky.  It  ap- 
pears in  the  form  of  a  liquid  with  a 
specific  gravity  of  0.689  at  60°  F.  and  a 
boiling-point  of  95°  F.  It  is  soluble  in 
water  in  the  proportion  of  1  part  to  9319 
parts,  and  is  readily  soluble  in  alcohol 
and  in  ether.  It  is  said  that  water  dis- 
solves 2.35  per  cent,  of  amylene-vapor, 
the  water  tasting  of  amylene  for  a  long 
time.  It  has  antiseptic  properties,  like 
nitrite  of  amyl,  and  prevents  the  putre- 
faction of  blood.  The  odor  evolved  from 
a  bottle  that  has  contained  blood  and 
amylene  resembles  that  of  rosemary. 
The  drug  prevents  decomposition  of 
fresh  flowers,  but  changes  their  color. 

Physiological  Action.  —  Amylene  was 
at  one  time  considerably  used  as  an  an- 
esthetic. It  causes  a  slight  excitement, 
a  rapid  inebriation,  followed  soon  after- 
ward by  weak  extremities,  sudden  col- 
lapse and  coma,  with  total  insensibility 
to  pain,  and,  though  rarely,  with  an 
equivalent  loss  of  consciousness.  Ex- 
periments on  human  beings  have  shown 
that  the  vapor  of  amylene,  by  inhalation, 
produces  a  state  of  anaesthesia  in  which 
acts  of  consciousness,  previously  con- 
ceived and  carefully  carried  out,  may  be 
performed,  without  remembering  after- 
ward any  single  fact  connected  with  the 
action.  This  is  a  remarkable  phenome- 
non, and  seems  to  show  that  the  human 


268 


AMYLENE-HYDRATE. 


brain  may  exhibit  objective  conscious- 
ness apart  from  the  subjective  conscious- 
ness of  life;  in  other  words,  a  conscious- 
ness of  which  it  is  itself  unconscious, 
and  this  under  the  mere  influence  of  a 
volatile  fluid  which  mixes  so  indifEer- 
ently  with  blood  at  98°  F.  that  one  part 
of  it  only  will  combine  with  a  little  over 
10,000  parts  of  blood.  This  action  of 
amylene  and  the  phenomena  of  somnam- 
bulism seem  to  present  a  certain  analogy. 

Untoward  Effects.  • —  in  sufficiently- 
large  doses  amylene  produces  death,  and 
the  only  post-mortem  change  observed 
is  engorgement  of  the  right  heart.  No 
change  in  the  color  of  the  blood  is  pro- 
duced; neither  is  there  any  alteration  in 
the  corpuscles  or  in  the  natural  period 
of  coagulation  of  the  blood  observed.  It 
lessens  muscular  power,  but  this  effect 
is  not  lasting.  The  fatal  action  of  amy- 
lene is  attributed  not  to  any  inherent 
powers  of  its  own,  but  to  the  fact  that 
when  the  drug  finds  access  to  the  circu- 
lation it  separates  in  the  form  of  vapor, 
producing  bubbles,  and  thus  acts  like  air 
introduced  into  a  vein. 

Therapeutics.  —  The  insensibility 
caused  by  amylene  is  quite  complete,  but 
exceedingly  transient.  After  the  drug 
is  removed,  recovery  is  rapid.  Before 
complete  insensibility  is  produced,  three 
well-marked  stages  are  observed:  The 
first  is  one  of  mild  excitement,  during 
which  the  face  becomes  red  and  con- 
gested; the  second  is  a  period  of  stag- 
gering inebriety;  and  the  third  stage  one 
of  collapse  and  insensibility.  A  peculiar 
muscular  tremor  is  frequently  noticed. 
Locally,  in  the  form  of  a  spray,  amylene 
acts  as  an  efficient  anaesthetic,  being 
more  rapid  than  anhydrous  ether  and 
more  stable  than  amyl-hydride,  which 
it  closely  resembles  in  its  physiological 
action.      (Benjamin   Ward   Richardson.) 


AMYLENE-HYDEATE.  —  Amylene- 
hydrate,  a  tertiary  amyl-alcohol,  is  a 
volatile,  colorless  liquid  giving  oi£  an 
unpleasant  peppermint-like  odor.  It  is 
soluble  in  eight  parts  of  water  and  is 
miscible  with  alcohol  in  almost  all  pro- 
portions. It  was  introduced  by  von 
Mehring  as  an  hypnotic,  and  has  since 
held  a  favorable  position  as  such. 

Dose.  ■ —  For  adults,  the  dose  is  30  to 
45  minims  by  the  mouth,  and  40  to  75 
minims  by  the  rectu.m.  It  should  be  kept 
in  well-stoppered  bottles.  The  disagree- 
able taste  may  be  avoided  by  administer- 
ing it  in  capsules. 

The  following  formula  has  been  rec- 
ommended as  efficient,  while  agreeable  to 
the  patient  as  well: — 

IJ   Amylene-hydrate,  1  drachm. 
Water,  2  ounces. 
Orange-fiower  water,  2  ounces. 
Syrup  of  bitter  orange,   1   ounce. 
— M. 

Of  this  mixture  one-half  may  be  taken 
at  night.  Amylene-hydrate  leaves  no 
bad  taste  in  the  mouth  or  disagreeable 
odor  on  the  breath  on  awaking,  such  as 
are  noticed  after  paraldehyde.  The  dose 
need  not  be  increased,  as  a  rule,  even 
after  repeated  use. 

Morphine  may  sometimes  prove  a  val- 
uable adjunct  to  amylene-hydrate  when 
an  analgesic  effect  is  also  required.  The 
following  formula  has  been  recommended 
by  Fischer: — • 

I^   Amylene-hydrate,  1  V2  drachms. 
Morphine  hydrochlorate,  V4  grain. 
Distilled  water,  3  ounces. 
Extract  of  licorice,  2  V2  drachms. 

M.  Sig.:  To  be  taken  in  two  doses 
two  hours  apart. 

If,  owing  to  the  nature  of  the  case, 
it  is  necessary  to  administer  the  above 
agents  by  the  rectum,  the  following  may 
be  used: — 


AMYLENE-HYDRATE.     PHYSIOLOGICAL  ACTION.     THERAPEUTICS. 


269 


IJ  Amylene-hydrate,  1  drachm. 

Morphine  hydrochlorate,  V^  grain. 
Mucilage  of  acacia,  5  drachms. 
Water,  1  Va  ounces. — M. 

Physiological  Action. — Like  alcohol,  it 
first  excites  and  then  successively  para- 
lyzes all  the  nerTC-centres.  Toxic  doses 
paralyze  the  cord  and  medulla,  finally 
abolish  reflex  activity,  arrest  respiration, 
and  paralyze  the  heart.  The  fatal  doses 
were  found  to  be  15  to  30  minims  per 
kilogramme  weight  of  animal.  A  very 
marked  diminution  of  temperature  is 
produced,  intensifying  the  danger  of  life. 
Muscular  spasms  produced  by  poisons, 
such  as  santonin  and  picrotoxin,  are  de- 
layed or  alleviated.  It  cannot  be  em- 
ployed subcutaneously,  owing  to  the 
severe  pain  produced.  (Harnack  and 
Meyer.) 

As  an  active  antipyretic  in  warm- 
blooded animals  it  has  also  been  credited 
by  Harnack  and  Meyer  with  considerable 
power.  The  smaller  the  animal,  the 
more  marked  the  fall  in  temperature, 
which  sometimes  is  as  much  as  11°  C. 
(19.8°  F.):  from  38°  to  27°  C.  (100.4° 
to  80.6°  F.).  This  lowering  is  due  to 
the  direct  action  of  the  drug  iTpon  the 
thermic  centres;  at  all  events,  the  dila- 
tation of  the  vessels  is  less  pronounced 
than  after  the  administration  of  chloral- 
hydrate.  In  man,  however,  amylene-hy- 
drate does  not  influence  the  temperature 
to  any  degree,  even  in  fever,  and  clinical 
observations  are  necessary  to  prove  its 
value.  It  acts  but  feebly  upon  the  res- 
piration, heart,  and  vessels  of  warm- 
blooded animals;  in  man  the  sphygmo- 
graph  shows  some  modifications  in  the 
pulse-curve.  Experiments  made  upon 
the  isolated  frog's  heart  and  the  muscles 
in  general  show  it  to  be  a  muscular 
poison;  the  muscles,  at  first  excited, 
become  paralyzed.    It  is  regarded  as  an 


excellent  antidote  to  all  convulsants, 
espiecially  when  the  convulsions  are  of 
cerebral  origin  (as  in  poisoning  by  san- 
tonin). Given  internally,  it  diminished 
the  elimination  of  urea;  but,  adminis- 
tered subcutaneously,  it  augmented  its 
elimination.  This  latter  phenomenon  is 
due  to  its  local  irritating  action  (phleg- 
monous inflammation,  abscess,  or  necro- 
sis of  the  tissues). 

The  property  possessed  by  amylene- 
hydrate  of  modifying  secretions  has  been 
generally  lost  sight  of,  according  to 
Brackmann,  Scharschmidt  alone  having 
noted  that  some  patients  perspire  at 
the  beginning  of  its  use.  In  the  single 
instance  in  which  it  was  used,  a  ease  of 
diabetes,  an  evening  dose  of  50  grains 
diminished  the  thirst,  lessened  the  quan- 
tity from  230  to  100  ounces,  and  raised 
the  specific  gravity  from  1005  to  1011 
in  six  days.  On  the  omission  of  the 
remedy  the  symptoms  returned. 

Amylene-hydrate  Poisoning.  —  Un- 
toward effects  were  noted  by  Dietz.  In 
four  instances  a  large  overdose  was  given 
through  neglect  to  shake  the  bottle  in 
which  the  drug  was  mixed  with  syrup; 
deep  sleep  followed,  from  which  the  pa- 
tients could  not  be  aroused.  There  was 
total  paralysis  and  suppression  of  tactile 
sensibility,  including  that  of  pain,  and  of 
corneal  reflex.  The  pupils  were  dilated, 
and  reacted  but  slowly  to  light.  Ees- 
piration  was  retarded,  superficial,  and 
irregular;  the  pulse  small,  soft,  and  slow; 
the  temperature  lowered  in  two  cases  to 
95°  F.  Artificial  respiration  was  required 
in  the  case  of  one  patient.  During  re- 
covery there  were  confusion  of  ideas  and 
inco-ordination  of  bodily  movements. 
The  author  likens  the  toxic  effect  to  that 
produced  by  alcohol.  He  advises  that  to 
avoid  such  accidents  the  drug  be  admin- 
istered in  capsules. 

Therapeutics. — Amyl-hydrate  is  justly 


270 


AMYLENE-HYDRATE.    THERAPEUTICS. 


considered  by  the  majority  of  observers 
as  an  excellent  hypnotic.  It  may  be  ad- 
ministered during  long  periods,  owing 
to  a  quality  not  possessed  by  chloral: 
i.e.,  it  does  not  tend  to  increase  nitrog- 
enous waste. 

Experiments  showing  that  the  action 
of  amylene-hydrate  is  entirely  opposite 
to  that  of  chloral-hydrate,  the  latter  in- 
creasing the  quantity  of  nitrogen  elimi- 
nated by  the  urine,  the  former  lessening 
it  about  two  grammes.  That  -excreted 
by  the  faeces  showed  no  change.  Amy- 
lene-hydrate, therefore,  prevents  the  de- 
struction of  albuminous  substances,  and 
it  is  preferable  as  a  narcotic  to  chloral- 
hydrate  whenever  the  hypnotic  effects 
are  to  be  continued  for  a  long  time,  and 
in  all  affections  in  which  there  is  an 
exaggerated  decomposition  of  albumi- 
noids; fever,  more  or  less  intense;  very 
pronounced  dyspnoea;  anaemia  and  hectic 
diseases,  especially  pulmonary  phthisis 
and  diabetes;  and  also  cases  of  digestive 
troubles  with  concomitant  anorexia.  J. 
Reiser  (Fortschritte  der  Med.,  No.  1, 
'93). 

It  is  especially  in  the  insomnia  of 
mental  disorders  that  it  has  been  em- 
ployed. Headache  sometimes  follows  its 
use. 

It  acts  especially  well  in  insomnia 
resulting  from  nervousness,  excessive 
mental  exertion,  anemia,  fevers,  cardiac 
diseases,  insanity,  and  after  the  with- 
drawal of  narcotics  that  have  been  con- 
stantly used.  It  is  contra-indicated  in 
insomnia  from  pain,  cough,  and  fre- 
quently in  cardiac  and  ursemic  dyspncea, 
and  in  gastric  disorders  attended  with 
irritation  or  nausea,  but  in  such  cases  its 
administration  by  the  rectum  is  followed 
by  the  usual  beneficial  results.  Many 
patients  and  children  do  not  tolerate  it 
on  account  of  its  taste  and  odor,  but  it 
is  readily  taken  when  administered  in 
soft  capsules.  Unusual  effects  are  pro- 
duced only  by  large  quantities,  and  con- 
sist in  loss  of  reflexes,  paralysis  of  ex- 


tremities, mydriasis,  low  temperature, 
feeble  pulse,  and  shallow  respiration. 
No  cases  have  been  observed  in  which  an 
amylene-hydrate  habit  was  engendered, 
or  a  cachexia  developed,  due  to  the  rem- 
edy.    (W.  H.  Flint.) 

To  produce  sleep  in  the  above  dis- 
orders it  may  be  administered  by  the 
mouth  or  by  enema  with  gitm  arable 
and  water.  Unlike  chloral,  it  has  no 
irritative  action  on  the  mucous  mem- 
brane of  the  rectum.  Sleep  comes  on 
after  fifteen  to  forty-five  minutes,  though 
often  sooner,  and  occasionally  no  effect 
at  all  is  produced.  On  the  whole,  it  is 
a  reliable  hypnotic,  if  given  in  sufficient 
dose:  two  to  three  times  as  large  as  that 
of  chloral,  though  it  is  somewhat  less 
certain  in  its  effects  than  is  this  substance 
or  morphine.  Unpleasant  secondary  ef- 
fects, as  excitement  or  slight  drunken- 
like  stupor,  are  very  seldom  witnessed. 
It  does  not  lose  its  efficiency, — though 
given  during  three  months  in  some  cases, 
— and  the  deep  and  refreshing  sleep  is 
praised  by  the  patient  oftener  than  in 
the  case  of  any  other  hypnotic.  The 
drug  is  more  powerful  than  paraldehyde 
or  urethan,  and  is  to  be  preferred  to 
them.  It  should  always  be  chosen  in 
heart  disease  in  place  of  chloral,  though 
it  is  not  so  strong  as  the  latter.  It  is 
fully  equal  to  sulphonal,  and,  indeed, 
superior  to  it  in  many  respects.  Three 
capsules,  each  containing  15  minims,  are 
easily  taken  on  retiring,  and  will  almost 
certainly  produce  sleep.  The  effect  fol- 
lows much  more  promptly  than  after 
sulphonal,  and  it  has  not  the  same  tend- 
ency to  produce  sleepiness  and  giddiness 
on  the  following  day.  (E.  Kirby  and  J. 
P.  C.  Griffith.) 

Epilepsy.  —  Evidence  is  not  lacking 
to  show  that  it  is  valueless  and  even 
dangerous  in  epilepsy.  Umphenbach 
noticed   from  its  use  increased   mental 


AMYLENE-HYDRATE. 


AMYLIFORM. 


271 


confusion  and  decided  disturbance  of 
sleep.  Dunn  experimented  upon  four- 
teen cases.  He  noticed  from  the  drug 
at  first  an  apparent  transient  improve- 
ment in  some  cases,  though  in  others 
the  number  and  severity  of  the  attacks 
were  increased  from  the  beginning.  A 
marked  tendency'  to  the  development  of 
status  epilepticus  manifested  itself  in 
some  cases,  while  others  sank  into  a  state 
of  coma,  with  subnormal  temperature 
and  slow,  heavy  respiration.  The  men- 
tal condition  of  patients  under  this 
treatment  did  not  improve  at  all,  even 
in  those  which  appeared  at  first  to  be 
benefited  in  the  ninnber  of  attacks. 

Insanity. — Amylene-hydrate  has  been 
thoroughly  tried  in  cases  of  mental  dis- 
order. It  is  an  hypnotic  of  a  high  order, 
occupying  a  position  between  paralde- 
hyde and  chloral.  It  is  superior  to  the 
first  in  its  less  injurioiTS  action  on  the 
heart,  and  to  the  second  in  the  absence 
of  unpleasant  odor  on  the  breath. 

In  a  large  number  of  cases  Lehmann 
obtained  good  results,  though  in  mania 
large  doses  were  required.  Paralysis  of 
the  insane  was  benefited,  but  the  in- 
somnia of  melancholy  was  aided  to  a 
less  degree.  Lehmann  considers  it  more 
efficacious  and  less  unpleasant  than 
paraldehyde.  It  is  quite  effective  in 
alcoholic  delirium. 

In  149  observations  83  per  cent, 
showed  marked  benefit,  15  to  75  minims 
.  being  administered.  Large  doses  were 
required  in  mania;  tlie  insomnia  of  mel- 
ancholia was  aided  to  a  lesser  degree 
than  that  of  other  disorders.  It  is  more 
efficacious  and  less  unpleasant  than 
paraldehyde.  Lehmann  (Ther.  Monat., 
Dec,  '87). 

In  300  observations  sleep  came  on  be- 
tween 15  and  45  minutes;  occasionally 
no  effect  was  produced.  Although,  as 
a  rulCj  no  unpleasant  secondary  effects 
were  noted,  37  minims  caused  a  condi- 
tion resembling  drunkenness  in  an  hys- 


terical woman.     Avellis   (Deutsche  med. 
Woch.,  No.  1,  '88). 

Opium  Habit. — Sleep,  lasting  through 
the  night  with  but  little  or  no  intermis- 
sion, was  obtained  by  Kirby  and  Griffith 
in  a  case  of  opium  habit,  in  which  chlo- 
ral, bromides,  paraldehyde,  and  hyoscine, 
given  singly  or  variously  combined,  had 
produced  but  indifferent  results.  Like  re- 
sults have  been  noted  by  other  observers. 

PuLMONAET  DisoEDEES.  —  In  pulmo- 
nary disorders,  G.  Mayer  found  amylene- 
hydrate  a  reliable  and  pleasant  hypnotic. 
It  appeared  not  only  to  produce  sleep, 
but  to  have  a  decided  sedative  influence 
on  the  cough.  In  phthisis  it  proved  it- 
self useful  in  this  respect,  after  morphia 
had  had  but  little  effect.  When  there 
is  pain  or  very  troublesome  cough,  how- 
ever, it  is  not  so  uniformly  successful. 

AMYLIFORM.— Amyliform  is  a  true 
chemical  combination  of  formaldehyde 
and  starch.  It  occurs  in  the  form  of  a 
white  powder,  without  odor,  insoluble  in 
all  liquids,  and  is  very  stable  and  not 
easily  altered.  It  is  gritty,  or  feels  like 
sand  when  rubbed  in  the  hands.  In  the 
body  it  is  decomposed  slowly  into  formic 
aldehyde  and  starch. 

Therapeutics. — Formic  aldehyde  being 
a  powerful  bactericide,  antifermentative, 
and  antiputrefactive,  amyliform  proves 
useful  in  antiseptic  surgery.  Employed 
as  a  powder,  it  was  found  to  diminish  in 
a  rapid  manner  the  secretions  upon  sores, 
particularly  those  which  have  a  bad  odor. 
It  is  strongly  antiseptic,  deodorant,  and 
absorbent. 

Amyliform  is  absolutely  free  from  ir- 
ritating properties,  and  non-toxic.  It 
favorably  affects  the  secretion,  prevents 
tissue-necrosis,  does  not  form  a  dry 
crust  which  retains  secretion,  and  will 
absolutely  prevent  the  foul  odor  from 
gangrenous  wounds.  Classen  (Therap. 
Monat,  Jan.,  '97). 


272 

AMYL-NITRITE. 


AMYL-VALERIANATE. 


ANiEMIA. 


See  NiTEiTES. 


AMYLOID  LIVEK. 

EASES    OF. 


See  Lives,  Dis- 


AMYL- VALERIANATE. — Amyl-vale- 
rianate,  introduced  by  Blanc,  represents 
the  odoriferous  principle  of  the  apple: 
that  is,  the  essence  extracted  by  distil- 
lation together  with  alcohol. 

Dose. — Its  toxic  properties  being  very 
slight,  as  many  as  5  or  6  capsules,  con- 
taining 2  grains  each,  can  be  taken  daily, 
but  it  is  necessary  to  guard  against  gas- 
tric disturbance. 

Physiological  Action. — Cider  has  long 
been  believed  by  the  laity  to  have  some 
effect  on  calculous  formations,  and  this 
seems  to  be  borne  out  by  the  fact  that 
valerianate  of  amyl  really  has  some 
solvent  action  on  cholesterin.  It  is  a 
colorless  liquid,  of  pleasant  taste  when 
taken  in  .small  quantities,  and  can  be 
prepared  in  the  laboratory  by  the  action 
of  valerianic  acid  on  amylic  alcohol. 
Fifteen  grains  of  cholesterin  are  dis- 
solved by  70  grains  of  valerianate  at  99° 
F.,  and  by  46  grains  at  104°  P. 

Therapeutics. — Physiologically,  its 
action  resembles  that  of  ether,  but  the 
special  qualities  lie  in  its  being  a  stimu- 
lant and  sedative  to  the  liver  in  cases  of 
hepatic  colic.  It  is  said  not  only  to  im- 
mediately subdue  the  attack,  but  to  pre- 
vent recurrences.  If  the  stomach  is  irri- 
table, it  may  be  necessary  first  to  employ 
sulphuric  ether,  following  this  with  2  or 
3  capsules  of  2  grains  each,  given  every 
half-hour  until  the  crisis  is  past,  and 
continued  at  long  intervals  during  the 
following  days.  According  to  Blanc,  in 
nephritic  colic  the  drug  acts  as  an  anti- 
spasmodic and  general  stimulant  only, 
but  no  effect  is  produced  on  the  renal 
calculi;  muscular  rheumatism  is  fre- 
quently relieved,  and  much  benefit  is  also 


derived  from  its  use  during  menstrual 
uterine  contractions.  It  is  also  consid- 
ered valuable  as  a  sedative  in  hysterical 
manifestations. 

AN.a;MIA. — From  Gr.,  d,  priv.,  and 


aLf.ia. 


blood. 


Definition. — A  symptomatic  disorder  of 
the  blood  characterized  by  a  deficiency  of 
some  of  its  important  constituents,  espe- 
cially red  corpuscles. 

Varieties. — Anaemia  may  be  classified 
into  two  general  forms:  (1)  that  due  to 
defective  haemolysis  and  (2)  that  due  to 
defective  haamogenesis.  Stephen  Mac- 
kenzie recognizes  four  degrees  of  anaemia 
according  to  the  number  of  red  corpus- 
cles present  in  the  blood,  but,  with  other 
observers,  he  regards  the  classification 
given  by  Hayem,  in  which  the  proportion 
of  haemoglobin  in  the  corpuscles  is  taken 
as  a  standard,  as  more  scientific.  This 
is  especially  the  case,  since  the  number 
of  red  blood-corpuscles  has  not  been  con- 
sidered as  important  a  factor  as  it  was 
once  held  to  be. 

According  to  Germain  See,  alterations 
of  the  blood  in  true  anaemia  are  conform- 
able to  one  of  three  types:  (1)  the  anae- 
mia from  hemorrhage,  characterized  by 
a  diminution  in  toto  of  all  the  elements 
of  the  blood;  (2)  a  type  characterized  by 
hypohaemoglobinfflmia, — i.e.,  a  deficiency 
of  haemoglobin,  either  quantitative  or 
qualitative;  (3)  a  type  in  which  the  num- 
ber of  red  blood-corpuscles  is  reduced. 

Symptoms.  —  The  main  symptom  of 
this  condition  is  an  abnormal  pallor  of 
the  skin  and  mucous  membranes,  which 
varies  in  different  cases  from  yellow  to 
absolute  whiteness.  The  finger-nails  also 
show,  by  their  whiteness,  the  general 
condition  present.  The  pallor  is  asso- 
ciated with  various  phenomena  indicat- 
ing involvement  of  the  nervous  system. 
Marked  depression  of  physical  and  men- 


ANAEMIA.    DIFFERENTIAL  DIAGNOSIS. 


273 


tal  powers  is  evident;  there  is  tendency 
to  inertia  or  indolence,  especially  during 
digestion.  Inordinate  palpitations  are 
frequent,  this  condition  causing,  in  the 
patients,  a  state  of  continuous  fear  as 
regards  the  presence  of  heart  disease  and 
anxiety  concerning  their  general  health. 
Shortness  of  breath  on  exertion,  head- 
ache, and,  in  women,  menstrual  disturb- 
ances, amenorrhcea  especially,  and  con- 
stipation, are  also  complained  of.  The 
surface  of  the  body  is  cool  and  the 
extremities  are  usually  cold.  Sensitive- 
ness to  the  variations  of  temperature  is 
the  rule. 

The  urine  has  a  low  specific  gravity 
through  deficiency  of  urea.  The  globes 
of  the  eyes  may  appear  blue,  owing  to 
semitransparency  of  the  conjunctiva. 

Auscultation  over  the  vessels  of  the 
neck  reveals  a  venous  hum;  this  symp- 
tom is  often  absent  in  mild  cases,  how- 
ever. A  systolic  bellows-murmur  is  also 
frequently  heard  over  the  carotid  arter- 
ies. A  systolic  murmur  is  occasionally 
heard  over  the  aorta  and  the  pulmonary 
artery.  These  are  valuable  guides  when 
the  effects  of  treatment  are  to  be  closely 
watched,  their  intensity  varying  with 
that  of  the  degree  of  anemia  present. 

Alterations  in  the  size  of  the  heart  in 
anaemic  subjects.  Dilatation  is  com- 
monly met  withj  and  sometimes,  espe- 
cially in  chlorosis,  elevation  of  the 
diaphragm  displaces  the  heart  upward 
and  an  apparent  dilatation  is  found. 
Anaemic  dilatation  is  to  be  considered 
true  idiopathic  dilatation  resulting  from 
overstrain.  None  of  the  usual  symptoms 
are  present;  gastralgia  alone  is  com- 
plained of.  Wybauw  (Jour.  Med.  de 
Bruxelles,  Mar.  15,  1900). 

Ansemio  dyspnoea  is  mainly  due  to 
vasomotor  failure;  the  disease  is  preva- 
lent in  the  female  sex,  whose  vasomotor 
system  is  more  unstable  than  that  of  the 
male;  it  usually  occurs  at  puberty,  when 
this  system  is  unusually  active.    J.  Hen- 

1- 


ton  White  (Birmingham  Med.  Eev.,  Oct., 
1900) . 

Case  of  simple  anaemia  in  a  young  mu- 
latto in  which  the  disease  followed  preg- 
nancy. On  admission,  examination  of 
the  blood  showed  12  per  cent,  of  haemo- 
globin, 750,000  blood-cells,  and  33,000 
wliite  cells.  The  case  is  classed  as  one 
of  simple  anaemia  because  of  the  rapidity 
and  degree  of  the  recovery.  Floyd  and 
Gies  (Med.  Record,  Apr.  27,  1901). 

Case  in  a  woman,  aged  38  years,  who 
had  suffered  from  anaemia  for  twelve 
years,  attended  by  repeated  nasal  dis- 
charge of  blood  and  pus.  Examination 
of  the  blood  showed  23  per  cent,  of  haem- 
oglobin, 475,000  red  blood-corpuscles, 
1400  white  corpuscles,  color  index  of 
2.40,  and  the  presence  of  nucleated  red 
cells,  both  normoblasts  and  megalo- 
blasts.  Under  treatment  a  great  im- 
provement resulted,  but  a  recurrence  of 
the  blood-disorder  took  place  and  death 
resulted.  The  case  is  thought  to  have 
been  one  of  secondary  anaemia  which  had 
passed  into  pernicious  anaemia.  W. 
Edgecombe  (Brit.  Med.  Jour.,  May  4, 
1901). 

Differential  Diagnosis.  —  The  symp- 
tomatic evidence  is  such,  in  the  majority 
of  cases,  as  to  readily  suggest  the  true 
nature  of  the  disease.  It  is  to  be  dif- 
ferentiated from  the  more  severe  forms: 
chlorosis,  pernicious  anaemia,  leucocy- 
thsemia,  and  pseudoleucocythsemia. 

Chloeosis.  —  The  greenish  pallor  of 
this  disease  is  quite  characteristic.  The 
reduction  of  hemoglobin  is  dispropor- 
tionate as  compared  to  the  number  of 
red  cells,  which  is  not,  as  a  rule,  greatly 
reduced. 

Pernicious  Anemia. — Examination 
of  the  blood  is  required  to  thoroughly 
establish  the  diagnosis,  although  the 
lemon-colored  skin  peculiar  to  these 
cases  is  quite  distinctive. 

Leucoctth^mia.  —  The  diagnosis  is 
early  established  by  the  microscope, 
which  shows  the  increase  of  white  cor- 
puscles, their  ratio  to  the  red  corpuscles 


274 


ANEMIA.    ETIOLOGY.    PATHOLOGY. 


being  sometimes  1  to  30  instead  of  1  to 
600,  the  normal  proportion. 

PSEUDOLEUCOCTTH^MIA. In  thiS 

disease  tlie  presence  of  enlarged  glands 
is  characteristic. 

Etiology.  ■ —  The  principal  causes  of 
benign  ansemia  are:  (1)  loss  of  blood, 
haemorrhages;  (2)  improper  assimilation 
of  nutritive  products  or  insufficiency 
of  blood;  (3)  abnormal  expenditure  of 
blood-constituents,  as  in  pregnancy  and 
lactation.  The  first  etiological  factor  is 
especially  common  in  women,  menor- 
rhagia,  metrorrhagia,  and  abnormal 
bleeding  during  labor  being  the  most 
frequent  causes.  The  second  class  affects 
the  poor,  in  the  majority  of  instances, 
through  lack  of  proper  food,  insufficient 
sunlight,  and  crowded  quarters,  to  which 
exposure  to  a  vitiated  atmosphere  the 
greater  part  of  the  time  is  added.  The 
third  class  of  cases,  those  due  to  preg- 
nancy and  lactation,  are  frequently  met 
with,  and  explain,  with  the  other  causes, 
the  greater  frequency  of  ansemia  in 
women  than  in  men.  The  latter,  how- 
ever, are  more  exposed  to  another  class 
of  causes, — that  due  to  introduction  into 
the  system  of  such  toxic  agents  as  lead, 
malaria,  etc., — which  also  tend  to  cause 
organic  alterations  of  the  blood-constit- 
uents. 

Anaemia  occurring  in  anchylostomiasis 
is  often  due  to  the  habit  frequently  as- 
sociated with  the  disease:  of  eating  dirt. 
This  often  gives  rise  to  oedema  of  the 
face  and  feet,  anaemia,  emaciation,  and 
exhaustion.  A.  J.  B.  Duprey  (Lancet, 
Oct.  27,  1900). 

Histories  of  four  of  fifteen  cases  of 
splenic  anaemia  described  in  a  previous 
paper.  The  etiology  of  the  disease  is 
not  known.  Heredity  usually  plays  no 
part;  but  Brill  has  reported  three  cases 
in  one  family.  Among  the  symptoms 
are,  first,  the  remarkable  duration  of 
the  disease;  the  enlargement  of  the 
spleen     withoui     apparent     cause;     the 


haematemesis  recurring  for  a  number  of 
years;  the  anaemia,  which  is  character- 
ized by  a  moderate  reduction  of  the 
number  of  corpuscles,  a  great  reduction 
in  the  percentage  of  haemoglobin,  and 
leucopenia.  There  is  often  pigmenta- 
tion or  bronzing  of  the  skin.  In  some 
of  the  patients  cirrhosis  of  the  liver 
occurs,  and  in  a  small  number  ascites 
is  present.  Among  the  other  symptoms- 
jaundice  sometimes  occurs.  The  condi- 
tion found  in  the  spleen  is  chiefly  a 
fibrosis  or  hyperplasia,  with  atrophy  of 
the  pulp  and  hyaline  degeneration  of 
the  Malpighian  bodies,  or  a  change  by 
which  the  normal  texture  is  largely  re- 
placed by  fibrous  tissue  and  large  en- 
dothelial cells  with  clear  protoplasm 
containing  two  or  more  nuclei,  and 
among  them  giant  cells.  The  disease- 
probably  represents  a  chronic  toxic^ 
rather  than  an  infectious,  process.  The. 
best  name  is  probably  splenic  anaemia. 
The  treatment  consists  in  splenectomy. 
In  the  author's  series  it  was  performed 
on  three  patients,  two  of  whom  died  as 
a  result  of  the  operation.  W.  Osier 
(Amer.  Jour  Med.  Sciences.,  Nov.,  1902). 

Pathology. — There  may  be  a  diminu- 
tion of  the  quantity  of  the  blood  in  the 
system,  a  deficiency  of  haemoglobin,  and 
reduction  of  the  number  of  red  corpus- 
cles or  of  other  constituents  of  the  blood, 
all  of  which  are  to  be  determined  by 
careful  examination.  The  quantity  of 
hsemoglobin  is  not  always  proportionate 
to  the  number  of  red  corpuscles,  the 
percentage  of  hemoglobin  in  the  latter 
being  subject  to  variation  according  to- 
the  character  of  the  disease  present.  In 
the  benign  form  of  antemia  treated  of 
in  this  article,  examination  shows  but  a 
slight  diminution  of  the  number  of  red 
corpuscles  and  a  relative  reduction  of 


Repeated  experiments  showing  the 
same  result,  that  the  production  of  the 
hsemoglobin  and  the  increase  in  the  num- 
ber of  red  corpuscles  depend  upon  differ- 
ent factors,  certain  substances  increas- 
ing one  while  others  increase  the  other... 


AN.EMIA.    TREATMENT. 


275 


Arsenic  certainly  increases  the  number 
of  red  blood-cells,  while  iron  causes  the 
production  of  new  haemoglobin.  F. 
Aporti  (Centralb.  f.  innere  Med.,  Jan.  13, 
1900). 

Basophile  granules.  To  determine 
whether  they  result  from  the  degenera- 
tion of  the  nuclei  or  the  cell-protoplasm 
itself,  an  artificial  anaemia  w-as  estab- 
lished in  several  rabbits  by  drawing  off 
as  much  as  one-third  of  their  blood.  The 
granules  were  not  found  at  once  after 
venesection,  but  appeared  one  or  two 
days  later,  chiefly  in  polychromatophilic 
cells,  and  many  of  these  without  gran- 
ules were  also  apparent.  The  late  ap- 
pearance of  these  changes  speak  for  cell- 
degeneration,  rather  than  breaking  down 
of  the  nucleus.  It  is  known  that  large 
losses  of  blood  are  followed  after  seveial 
days  by  an  hydrtemic  condition  of  the 
circulating  fluid.  This  is  also  seen  in  all 
forms  of  ansemia  except  chlorosis,  and  it 
stands  in  definite  relation  with  and  is 
the  chief  causative  factor  in  the  cell- 
changes.  M.  Cohn  (Miinchener  med. 
Woch.,  Feb.  6,  1900). 

In  all  cases  of  anaemia  uncomplicated 
with  glandular  involvement  there  is  an 
increase  in  the  percentage  of  lymphocytes 
and  correspondingly  a  diminution  in  the 
quantity  of  the  multinuclear  neuirophile 
elements.  Leucopenic  anaemias  asso- 
ciated with  glandular  disease  (spleen, 
lymphatic  glands)  show  a  varying 
quantity  as  to  the  relative  percentage 
between  the  multinuclear  and  uninuclear 
elements.  A.  V.  Decastello  and  Ludwig 
Hofbauer  (Zeits.  f.  klin.  Med.,  vol.  xxxix, 
Nos.  5  and  6,  1900). 

Treatment. — The  treatment  of  benign 
ansemia  may  be  summed  np  as  follows: 
(1)  on  removal  of  the  cause,  if  such  be 
found;  (2)  on  exercise  of  hygienic  meas- 
ures,— light,  air,  rest,  and  exercise;  and 
(3)  on  proper  medication.  Of  drugs, 
iron  stands  first,  and  is  especially  useful 
where  hamoglobin  is  greatly  reduced. 
Next  to  iron  is  arsenic:  useful  particu- 
larly where  haemoglobin  is  not  so  much 
reduced  as  the  corpuscles. 


Experiments  on  dogs  and  chickens  and 
search  through  literature  show  that  cop- 
per, zinc,  manganese,  and  mercury  act 
like  iron  in  cases  of  anaemia  and  chloro- 
sis. Under  their  use  the  haemoglobin 
readily  increases.  Cervello  (Jour,  dea 
Praticiens,  Jan.  12,  1901). 

Ansemia  being  in  reality  but  a  symp- 
tom, the  causative  affection  must  be  care- 
fully sought  after.  In  women,  as  stated, 
uterine  disorders  are  the  most  active 
factors.  In  young  girls  it  is  frequently 
met  with,  owing,  probably,  to  temporary 
inequality  in  the  development  of  various 
physiological  functions.  Hence  the  in- 
frequency  of  complications  in  such  cases. 
The  possibility  of  complications  should 
always  be  borne  in  mind,  however,  and 
every  precaution  taken  to  forestall  ag- 
gravated forms,  by  food  adjusted  to  the 
taste  of  the  patient  and  made  attractive 
to  her.  Disorders  of  digestion  usually 
yield  to  bismuth  and  aromatic  powder. 

As  result  of  investigations  into  effect 
of  exercise  on  haemoglobin  with  reference 
to  the  value  of  rest  and  treatment  of 
anaemia,  it  is  concluded  that  (1)  there 
is  a  normal  daily  fall  and  nightly  rise 
in  the  worth  of  the  corpuscle,  represent- 
ing a  daily  destruction  and  regeneration 
of  haemoglobin;  (2)  active  exercise  in- 
creases the  extent  of  the  daily  fall  and 
the  nightly  rise;  (3)  active  exercise 
stimulates  a  slight  overproduction  of 
haemoglobin;  (4)  passive  exercise  [mass- 
age] diminishes  the  volume  of  the  blood, 
but  has  no  effect  in  diminishing  or  in- 
creasing the  amount  of  haemoglobin;  (5) 
rest  reduces  the  extent  of  the  daily  fall 
in  worth,  representing  a  diminished  de- 
struction of  haemoglobin.  Wilfrid  Edge- 
combe  (Brit.  Med.  Jour.,  June  25,  '98). 

Although  iron  is  especially  effective- 
after  the  cause  of  the  disease  has  beep 
removed,  even  when  the  causative  ail- 
ment is  still  present  it  exercises  its 
beneficial  effects,  which  are  generally  as- 
cribed to  the  fact  that  iron  is  a  normal 
constituent  of  the  red  corpuscles. 


276 


AN.EMIA.    TREATMENT. 


As  regards  the  best  preparation  to  be 
employed,  it  is  difficult  to  make  a  selec- 
tion. Theoretically,  the  best  preparation, 
according  to  Herschell,  is  the  nascent 
ferrous  carbonate  formed  in  the  stomach 
itself  by  the  reaction  between  sulphate 
of  iron  and  carbonate  of  potash,  while 
the  worst  preparations  are  the  albumi- 
nates, peptonates,  and  colloid  forms.  In 
the  latter,  contact  with  the  hydrochloric 
acid  of  the  gastric  juice  produces  a  pre- 
cipitate of  insoluble  ferric  carbonate  of 
iron.  The  alleged  fact  that  these  prep- 
arations are  better  borne  in  disease  is 
evidently  due  to  the  fact  that  they  are 
almost  inert.  In  a  comparative  study 
of  the  subject,  during  which  the  hemo- 
globin was  estimated  both  before  and 
after  treatment  by  means  of  Fleischl's 
hsemometer,  Herschell  found  Blaud's 
pills  in  tabloid  form  to  be  the  most 
efEective,  having  shown  an  average  daily 
increase  of  1.2  per  cent,  of  haemoglobin. 
Ferratin  has  also  been  recommended  by 
many  observers.  Banholzer  observed  a 
5-per-cent.  increase  of  haemoglobin  in 
eight  days.  Whatever  preparation  is 
used,  it  should  be  changed  for  another 
after  a  few  weeks  and  returned  to,  if 
its  effects  have  manifested  themselves 
actively.  The  remedy  should  invariably 
be  administered  after  meals.  Anaemic 
patients  are  usually  imaginative  and 
frequently  assume  that  iron  will  not 
improve  their  condition.  They  must 
be  assured  that  they  will  be  benfited 
provided  the  instructions  given  them 
are  carefully  carried  out. 

Iron  exists  in  the  blood  only  in  the 
form  of  a  phosphate.  Soluble  citro- 
phosphate  of  iron,  for  the  production  of 
this  salt,  is  not  followed  by  constipation. 
Jolly  (Provincial  Medical  Journal,  May, 
'89). 

Albuminate  of  iron  is  especially  serv- 
iceable when  anaemia  and  debility  are 
associated  with  weak  and  irritable  di- 


gestive   organs.     John    A.    Ouchterlony 
(Amer.  Pract.  and  News,  Nov.  23,  '89). 

Blaud's  pills  preferred  to  any  other 
preparation  of  iron;  next  to  iron  comes 
arsenic.  Arsenic  acts  with  most  effect 
in  cases  in  which  the  relative  percentage 
of  haemoglobin  remains  normal  or  is 
actually  increased,  the  type  of  "which  is 
pernicious  antemia.  Laache  (Wiener 
klin.  Woch.,  Sept.  18,  '90). 

The  double  sulphate  of  iron  and  mag- 
nesium recommended  in  doses  of  10 
grains    three    times    a    day. 

B  Sulphate   of  iron  and  magnesium, 
2  drachms. 
Chloroform-water,  enough  to  make 
6  ounces. 

M.  Sig.:  Half  an  ounce  thi-ee  times 
a  day.  Woods  (Brit.  Med.  Jour.,  May 
23,  '91). 

Daily  dose  of  ferratin  for  adults  is  15 
to  23  grains.  Schmiedeberg  (Arch.  f. 
exp.  Path.imd  Pharm.,  B.  23,  H.  23,  '94). 

In  anaemia  following  acute  disease 
haemoglobin  quickly  increased  (over  5 
per  cent,  in  eight  days),  also  number  nf 
red  cells,  by  the  use  of  ferratin.  Banhol- 
zer (Centralb.  f.  klin.  Med.,  Jan.  27,  '94). 

In  marked  anaemia  and  chlorosis 
Blaud's  pills  in  large  doses  recom- 
mended. As  many  as  forty-eight  on  the 
fourth  day  have  been  given  and  con- 
tinued for  three  or  four  weeks.  It  is 
necessarj'  to  keep  the  patient  in  bed  in 
a  large,  airy  room;  hospital  patients  are 
more  likely  to  recover  quickly  than  pri- 
vate ones  for  this  reason.  Byrom  Braiu- 
well  (Med.  Record,  Aug.  22,  '97). 

The  most  satisfactory  result  is  ob- 
tained with  the  peptomanganate  of 
iron;  it  is  easily  absorbed  by  the  entire 
intestinal  tract,  and  evokes  no  concomi- 
tant effects.  In  12  out  of  23  cases  the 
haemoglobin  was  normal  after  fourteen 
days,  in  5  after  three  weeks,  and  in  5 
after  a  month.  In  acute  anaemia  good 
results  were  also  obtained  by  this  mode 
of  treatment.  H.  Metall  (Med.-Chir. 
Centralb.,  June,  1902). 

Some  eases  do  not  yield  to  the  prep- 
arations of  iron  as  long  as  constipation 
exists.  Aperients  may  either  be  given 
separately  or  with  the  iron.     Aloin  and 


AX.i:]VIIA.    TREATMENT. 


277 


belladonna   extract   are   useful   in   these 
cases. 

Iron  and  rhubarb  may  be  combined  as 
follows: — 

B  Protoxalate  of  iron. 

Powdered  rhubarb,  of  each,  1  grain. 

Make  into  a  cachet.  Give  two  or  three 
of  these  cachets  each  day.  Editorial 
(Jour,  des  Praticiens,  Mar.  28,  '96). 

Iron  may  be  administered  hypoder- 
mically.  This  method  is  of  great  value 
when  the  anemia  is  far  advanced  and  a 
sudden  reaction  becomes  necessary. 

The  subcutaneous  injections  of  iron 
salts  in  the  form  of  a  10-per-cent.  solu- 
tion of  iron  and  ammonium  citrate,  1 
grain  and  upward  of  the  dmg  being 
given  in  each  injection,  tried.  In  every 
instance  in  which  the  injections  were 
continued  sufficiently  long,  the  percent- 
age of  hsemoglobin  regularly  increased, 
and  simultaneously  the  phenomena  of 
ansemia.  both  subjective  and  objective, 
decreased.  This  shows  that  the  ansemic 
condition  can  be  markedly  benefited  by 
iron  when  given  subcutaneously.  Eiva- 
Kocci   (II  Polielinico,  Xo.  8,  p.  168,  "96). 

Case  of  grave  auEemia  in  which  pro- 
longed treatment  with  many  preparations 
of  iron  and  arsenic  taken  internally  pro- 
duced no  effect.  The  hjemoglobin  sank 
below  a  sixth  of  its  normal  amount.  The 
patient  apparently  dying,  subcutaneous 
injections  of  a  4-per-cent.  solution  of 
citrate  of  iron  tried,  45  to  60  minims 
being  injected  daily.  Marked  improve- 
ment took  place  almost  at  once,  and  the 
percentage  of  haemoglobin  rapidly  rose. 
In  a  month's  time  the  patient  was  con- 
valescent. 

A  4-per-cent.  solution  is  quite  strong 
enough.  The  10-per-cent.  solution  gen- 
erally employed  is  too  strong.  Hypo- 
dermic injections  of  3  grains  of  citrate 
of  iron  have  been  known  to  cause  vomit- 
ing and  fever.  The  kidney  is  liable  to 
be  damaged  by  too  concentrated  solu- 
tions, leading  to  anuria  and  haematuria 
and  even  nephritis.  Hypodermic  injec- 
tions of  iron  are  not  indicated  in  cases 
where  the  kidneys  are  not  sound.  E. 
Lepine  (La  Semaine  Med.,  May  26,  '97). 


While  iron  is  the  most  active  of  the 
chalybeates,  other  drugs  tend  to  increase 
blood-formation,  namely:  manganese, 
phosphorus,  arsenic,  hydrochloric  acid 
(indirectly),  and  oxygen.  Manganese 
sometimes  proves  useful  when  amenor- 
rhoea  is  present.  Phosphorus  and  arsenic 
encourage  nutrition  and  probably  act  as 
germicides,  preventing  ptomaine  forma- 
tion in  the  intestines. 

Waters  containing  small  quantities  of 
iron  give  better  and  quicker  results  than 
pharmaceutical  preparations,  and  all  the 
unfavorable  symptoms  so  often  produced 
by  the  latter  are  avoided.  Th.  Bernard 
(Gaz.  Med.  de  Paris,  Apr.  8,  '93). 

Iron  increases  in  a  marked  degree  oxi- 
dation, while  arsenic,  on  the  contrary, 
exerts  a  powerful  moderating  influence 
on  this  process.  The  indications  for  one 
of  these  drugs  are  consequently  exactly 
the  opposite  of  those  of  the  other. 
Treatment  by  iron  h  called  for  in  cases 
of  auEemia  with  reduced  co-eflScient  of 
oxidation,  whereas  arsenic  should  be 
ordered  when  the  oxidation  is  increased. 
A.  Robin   (Med.  Week.,  Apr. '2,  '97). 

Case  of  a  girl  of  20  who  had  tried  all 
remedies  recommended  in  anaemia,  but 
Avithout  effect.  Xettle-soup  ordered  first, 
every  second  day;  then,  when  she  im- 
proved, twice  a  week.  Patient  was  com- 
pletely cured.  The  author  himself  was 
cured  of  anaemia,  when  he  was  17,  by 
taking  nettle-soup.  The  common  or 
stinging  nettle  {Vrtica  dioica)  and  the 
dwarf  nettle  {Vrtica  wans)  possess  the 
same  virtues,  but  the  first  is  used  almost 
exclusively.  The  best  time  for  collection 
is  spring;  the  best  part  to  use  is  the 
roots  and  stalks  with  only  half-developed 
leaves.  It  may  be  used  as  an  infusion — a 
handful  to  two  quarts  of  water,  2  or  3 
glasses  of  this  to  be  taken  during  the 
day;  but  it  is  much  pleasanter  to  use 
in  the  form  of  a  freshly-prepared  soup 
from  the  fresh  herb.  Hjalman  Agner 
(Bull.  Gen.  de  Ther.,  June  8,  '98). 
Hfemoglobin  continued  until  the  nor- 
mal standard  is  reached — 1  V2  grains 
daily — has  met  with  favor.  If  there  is 
no  digestive  trouble,  other  preparations 


278 


AN.EMIA.     TREATMENT. 


of  iron  can  be  given  at  the  same  time, 
and  the  results  be  more  prompt. 

Haemogallol,  the  dose  of  which  is  1 
grain,  given  a  quarter  of  an  hour  before 
meals  gradually  increased  to  1  V2  grains 
and  over,  has  been  recommended  by  T. 
Lang  and  others. 

A  number  of  agents  have  been  rec- 
ommended with  the  view  to  lessen  the 
destruction  of  blood-corpuscles;  arsenic, 
quinine,  mercury,  phosphorus,  betanaph- 
thol,  iodoform,  carbolic  acid,  sulphocar- 
bolate,  and  menthol  represent  this  series. 
Arsenic  probably  accomplishes  this  in 
the  manner  indicated,  namely:  by  pre- 
venting the  formation  of  ptomaines. 

Direct  transfusion  of  blood  is  also  of 
value  in  cases  of  chronic  progressive 
ansemia,  by  stimulating  the  blood-mak- 
ing organs.  This  measure  is  sustained 
by  von  Ziemssen. 

The  introduction  of  goat's  serum  di- 
rectly into  the  veins,  using  about  50 
cubic  centimetres  (1  V*  ounces)  has  been 
advocated  by  Lepine. 

Striking  curative  results  have  been 
obtained  by  Simon  Baruch,  by  means  of 
hot-air  baths  in  boxes,  followed  by  cold 
douches. 

Hot  baths  in  more  than  fiftj'  eases  of 
ansemia   in   patients   who   for   the   most 
part  had  been  under  medical  treatment 
without  benefit.     A  bath  at  104°  F.  is 
given  three  times  a  week.     Its  duration 
should  not  exceed  fifteen  minutes,  and  at 
its  close  the  patient  should  be  douched 
with    cool    \\'ater.     Immediate   effect    of 
such  a  bath  is  a  feeling  of  lightness  in 
the  individual,  and  in  four  weeks'  or  a 
less  time  there  is  a  noticeable  improve- 
ment  in   the   general    condition.      Rosin 
(Centralb.  f.  innere  Med.,  Apr.  30,  '98). 
Hayem  in  1889  recommended  the  hyp- 
odermic injection  of  arsenical  prepara- 
tions in  cases  where  irritability  of  the 
stomach  prevented  its  administration  by 
the  mouth.     The  best  means  of  admin- 
istering Fowler's  solution  is  in  cherry- 


laurel  water,  in  10-drop  doses,  as  much. 

as  20  drops  being  sometimes  given  in  a 

day. 

Report  of  thirty-five  cases  of  severe 
anaemia  due  to  various  causes — such  as 
pernicious  anaemia ;  anaemia  after  typhoid 
fever,  round  ulcer,  cancer,  tuberculosis; 
and  that  due  to  tape-worm — in  which  a 
solution  composed  of  2  parts  of  water 
and  1  part  of  Fowler's  solution  was  em- 
ployed. Of  this  mixture,  an  ordinary 
hypodermic  syringeful  was  given  daily. 
In  all  instances  a  marked  improvement 
in  the  anaemia  noted.  Kering  (.Jour,  des 
Praticiens,  Jan.   18,  '96). 

Oxygen  does  not  possess  the  confidence 
of  the  profession,  although  some  rather 
remarkable  cases  have  been  reported. 

[Nothing  is  to  be  expected  from  oxy- 
gen, for  the  blood-corpuscles,  few  in 
number  though  they  be,  are  well  charged 
with  haemoglobin  and  consequently  with 
oxygen.  In  chlorosis  the  case  is  difl'er- 
ent.  F.  P.  Hekry,  Assoc.  Ed.,  Annual, 
'89.] 

In  marked  anaemia  and  chlorosis  the 
inhalation  of  oxygen  has  been  tried,  but 
without  much  benefit.  F.  Taylor  (Med. 
Record,  Aug.  22,  '97). 

Series  of  cases  in  which  oxygen  in- 
halations with  marked  benefit  were  used. 
The  most  interesting  was  that  of  a 
woman  of  22  with  grave  anaemia,  the  red 
cells  being  reduced  to  2,000,000,  the 
hasmoglobin  to  30  per  cent.,  and  the  red 
cells  were  much  defonned.  The  woman 
had  frequent  attacks  of  syncope  and  was 
veiy  weak.  Upon  the  failure  of  iron 
and  arsenic  treatment  she  was  given 
oxygen  inhalations,  and  rapidly  im- 
proved. Within  four  months  the  red 
cells  had  increased  to  4,000,000,  and  the 
hfemoglobin  was  about  normal.  She  ulti- 
mately became  entirely  well.  The  ap- 
paratus which  is  recommended  is  similar 
to  the  one  used  for  the  administration 
of  nitrous  oxide.  P.  G.  Lodge  (Lancet, 
Apr.  7,  1900). 
Insomnia  is  a  frequent  accompaniment 
of  anemia  and  tends  greatly  to  increase 
the  weakness  of  the  patient.  Amylene- 
hrdrate  is  the  best  a?ent  in  this  condi- 


ANiEMIA. 


ANEMIA,  PERNICIOUS. 


279 


tion,  30  to  45  minims  being  administered 

in  capsules  on  retiring. 

In  insomnia  of  anaemia,  amylene-hy- 
drate.  For  adults  the  dose  is  30  to  45 
minims  by  tlie  mouth,  or  40  to  75 
minims  by  the  rectum.  It  should  be 
administered  by  the  mouth  in  soft  cap- 
sules, or  in  a  solution  disguised  by  some 
aromatios.  The  mixture  should  be  well 
shaken  before  use,  to  avoid  an  overdose. 
W.  H.  Flint   (Ther.  Gaz.,  Jan.,  '90). 

Submammary  infusions  of  salt  solution 
in  primary  ansmia  from  haemorrhage,  in 
shock,  were  recommended  recently  by  J. 
G.  Glark.  As  a  stimulant  after  severe 
blood-loss  or  shock,  its  benefits  are  so 
marked,  and  the  procedure  so  free  from 
bad  results  of  any  kind,  that  it  has  been 
used  with  signal  success  by  Howard 
Kelly,  of  Baltimore,  in  41  of  the  last 
285  cases  of  abdominal  section  in  the 
Johns  Hopkins  Hospital. 

A  quart  of  0.6  sterilized  solution  of 
common  salt  is  used,  and  is  infused  into 
the  submammary  cellular  tissue  in  the 
following  manner:  A  bottle  containing 
the  solution  is  connected  by  five  feet  of 
rubber  tubing  to  a  slender  aspirating- 
needle.  The  breast,  after  being  carefully 
disinfected,  is  grasped  and  lifted  well 
from  the  thorax,  while  the  needle,  with 
the  fluid  flowing  from  it,  is  quickly 
thrust  beneath  the  gland.  Usually 
simple  elevation  of  the  bottle  is  suffi- 
cient to  force  the  fluid  into  the  loose 
cellular  tissue;  if  this  be  insufficient, 
stripping  the  tube  or  the  reversed  as- 
pirator pump  can  be  used.  The  breast 
rapidly  distends,  and  in  some  instances 
the  fluid  may  actually  spurt  from  the 
nipple.  After  a  quart  has  been  injected, 
the  needle  is  rapidly  withdrawn  and  the 
puncture  closed  with  adhesive  plaster. 
In  thirty  minutes  complete  absorption 
has  taken  place.  Manifest  improvement 
in  the  patient's  condition  is  rapidly 
apparent,  especially  with  regard  to 
pulse,  which  shows  greater  volimie  and 
strength,  while  the  patient  herself  feels 
better  and  is  brighter.  A  critical  stage 
occasionally  occurs  in  some  cases  within 
half  an  hour.     This  consists  in  a  violent 


chill,  with   sensations   of   extreme   cold, 
rise  in  temperature,  and  strong,  rapid 
pulse;   but  this  is  followed  by  a  marked 
reaction.     From  its  safety  this  procedure 
is  strongly  to  be  recommended  instead 
of   arterial   or   venous   infusion.    J.   G. 
Clark   (Amer.  Jour.  Obst.,  June,  '97). 
Bone-marrow  has  recently  been   ex- 
tensively used  in  anjemia,  with  varying 
results.    This  subject  is  reviewed  under 
Animal  Exteacts. 

Fourteen  cases  of  anaemia  in  tuber- 
culous joint  diseases  and  in  osteomalacia 
treated  by  the  administration  of  a  prep- 
aration of  red  bone-marrow  and  bullocks' 
blood  called  "carnogen."  The  substance 
was  given  in  2-drachm  doses  twice  daily, 
the  improvement  in  the  condition  of  the 
patients  as  rapid  as  it  was  marked  and 
sustained.  This  method  appears  to  be 
of  especial  use  in  cases  where  arsenic, 
iron,  strychnine,  and  codliver-oU  had 
been  exhibited  without  benefit.  C.  H. 
Jaeger  (N.  Y.  Med.  Jour.,  July  31,  '97). 

Action  of  red  bone-marrow  on  the 
blood  in  anjemia:  1.  Subcutaneous  injec- 
tions of  bone-marrow  have  no  action  on 
the  red  corpuscles  or  haemoglobin  of  a 
healthy  animal.  2.  When  the  red  cor- 
puscles and  haemoglobin  fall  below  their 
normal  limits,  injections  of  marrow  pro- 
duce a  decided  rise  in  both.  This  rise 
is  well  marked,  sudden,  and  of  short 
duration.  3.  Along  with  the  increase  in 
the  red  corpuscles,  there  is  no  correspond- 
ing improvement  in  the  form  of  the  cells. 
4.  The  active  principle  is  present  in  an 
aqueous,  but  not  alcoholic,  extract  of 
marrow;  it  is  not  precipitated  by  boil- 
ing, does  not  contain  iron,  and  may  pos- 
sibly be  a  deuteroproteose.  Fowler 
(Scottish  Med.  Jour.,  Sept.,  '99). 

Aiir.a;MiA,  peeniciotjs. 

Definition. — A  form  of  ansemia  which 
tends  toward  a  fatal  issue. 

Symptoms. — The  most  evident  symp- 
tom is  extreme  pallor  of  the  face  and 
body,  which  gradually  assume  a  lemon- 
yellow  tint.  This  yellowish  color  deep- 
ens as  the  case  progresses;  it  may  appear 
suddenly,  but  in  the  majority  of  cases  it 


280 


AN.EMIA,  PERNICIOUS.    SYMPTOMS.    DIAGNOSIS. 


develops  gradually,  following  the  insidi- 
ous course  of  the  disease. 

There  is  great  weakness  with  all  its  at- 
tending symptoms:  inordinate  palpita- 
tions and  dyspnoea  on  exertion,  sighing, 
and  slow  delivery  in  speaking. 

The  pulse  is  regular,  but  rapid,  in  the 
majority  of  cases,  more  or  less  fever  be- 
ing usually  present.  The  temperature  is 
extremely  irregular. 

Cardiac  murmurs  are  generally  heard, 
and  signs  of  fatty  degeneration  may  be 
detected  by  auscultation,  although  there 


Fundii.s  oeuli  in  a  case  of  pernioioiis 
anaemia,  showing  retinal  haemorrhages. 
(BramiveU.) 

is  usually  no  arterial  degeneration  or 
valvular  disease.  A  loud  venous  hum 
can  sometimes  be  detected  in  the  vessels 
of  the  neck,  ffidema  of  the  ankles,  face, 
and  lungs  and  dropsical  effusions  may 
appear  at  any  stage. 

Eetinal  hasmorrhage  is  a  symptom  of 
great  value.  There  may  also  be  haem- 
orrhages into  the  mucous  membranes, 
epistaxis,  menorrhagia,  and  purpuric 
eruptions  in  advanced  cases. 

Gastric  and  intestinal  disorders  are  the 
rule,  although  the  general  nutrition  is 


apparently  preserved,  the  appetite  be- 
ing sometimes  voracious,  and  the  patient 
becoming  obese.  Dyspepsia,  vomiting, 
and  diarrhcea  usually  prevail.  The  gas- 
tric region  is  tender  to  pressure,  and  the 
tongue  is  pale  and  smooth. 

Involvement  of  the  osseous  system  is 
occasionally  indicated  by  sensitiveness  of 
the  bones,  especially  those  of  the  ster- 
num. 

Drowsiness  is  present  in  the  majority 
of  cases,  but  insomnia  is  occasionally 
observed. 

Headache,  vertigo,  tinnitus,  apoplec- 
tiform attacks,  delirium,  and  other  dis- 
orders of  the  nervous  system,  such  as 
paresthesia,  neuralgia,  and  extensive 
paralyses,  have  been  noted. 

Absence  of  the  knee-jerk  is  often  pres- 
ent, and  is  indicative  of  degeneration  of 
the  posterior  columns  of  the  cord. 

Jaundice  is  occasionally  met  with. 

The  urine  is  dark  and  highly  colored; 
it  is  of  low  specific  gravity,  and  shows 
an  increase  of  urea  and  uric  acid  and 
pathological  urobilin. 

When  the  end  is  approaching  the 
temperature  recedes  markedly,  and  the 
patient  enters  into  a  torpid  condition, 
ending  in  coma. 

Diagnosis. — While  pernicious  anemia 
possesses  characteristics  that  readily  dis- 
tinguish it  from  other  blood  afEections, 
— the  color  of  the  skin,  the  retinal  hem- 
orrhages, etc., — the  early  stages  are  gen- 
erally s^Tch  as  to  suggest  diseases  that  do 
not  present  the  same  degree  of  danger. 

Benign  Anemia.  —  Intractability  of 
the  disease,  after  the  removal  of  supposed 
causes  and  the  faithful  use  of  appropriate 
measures  of  treatment,  strongly  suggests 
the  presence  of  pernicious  anemia. 

CHLOROSis.^From  this  affection  per- 
nicious anemia  may  readily  be  differ- 
entiated by  the  blood-examination.  In- 
stead of  relative  increase  of  hemoglobin, 


ANiEMIA,  PERNICIOUS.    ETIOLOGY. 


281 


the  presence  of  gigantoblasts,  marked 
oligoeytheemia,  and  macrocytes  differ- 
entiate. The  red  corpuscles,  in  chlorosis, 
may  be  normal  in  number  and  in  size, 
the  only  change  being  a  deficiency  of 
haemoglobin.  Again,  the  corpuscles  may 
be  normal  in  number,  but  diminished  in 
size,  while  the  percentage  of  haemoglobin 
is  normal;  finally  the  corpuscles  may 
be  diminished  in  number  with  either  a 
diminished,  normal,  or  perhaps  an  in- 
creased percentage  of  hemoglobin. 

Leucoctth^mia.  —  This  disease  may 
be  excluded  by  the  absence  of  the  char- 
acteristic blood-change:  excess  of  white 
corpuscles. 

PsEUDOLEUCOCYTH^MiA  is  excluded 
by  the  absence  of  the  affection  of  the 
lymphatic  glands  which  characterizes 
this  disease,  more  commonly  known  as 
Hodgkin's  disease. 

Leukemia.- — In  leukaemia  the  patient 
often  does  not  show  enough  pallor  to 
make  the  physician  suspect  the  disease. 
The  lips  have  a  dirty-red  color  rather 
than  a  peculiar  pallor.  The  number  of 
white  corpuscles  would  cause  pallor  in  a 
patient  with  simple  anemia,  but  in  this 
disease  the  opacity  of  the  blood  is  great 
and  the  pallor  fails  to  show.    (Janeway.) 

Gastkic  Cancee.  — ■  This  condition 
almost  always  shows  itself  after  the  age 
of  forty  years,  whereas  pernicious  ane- 
mia is  generally  observed  early  in  life. 
In  cancer  the  skin  is  pale;  in  pernicious 
anaemia  the  peculiar  lemon  color  is  strik- 
ing in  the  majority  of  cases.  While 
gastric  symptoms  and  absence  of  hydro- 
chloric acid  are  prominent  features  of 
cancer,  the  digestive  disorder  is  slightly 
marked  in  anemia  and  examination  of 
the  gastric  contents  is  negative.  Finally 
increasing  emaciation  attends  a  cancer- 
ous disorder,  whereas  in  cases  of  perni- 
cious anemia  the  patient  not  only  retains 
his  adipose  tissues,  but  sometimes  be- 


comes corpulent.    In  rare  cases,  however, 
there  was  extreme  emaciation. 

Attention  drawn  to  the  impossibility 
of  marking  off  pernicious  anaemia  from 
all  other  anfemias.  There  is  no  marked 
boundary-line;  one  ansemia  passes  in- 
sensibly into  another.  T.  G.  Stewart 
(Clinical  Joumal,  Sept.  14,  '98). 

The  difference  between  the  pernicious 
anseniia  and  other  grave  anaemias  lies  in 
the  clinical  course,  that  of  the  former  be- 
ing characterized  by  the  fact  that,  even 
after  the  removal  of  the  apparent  cause, 
the  hsemapoiesis  persists  in  a  faulty  di- 
rection,  manifested   by   insufficient   new 
formation  and  perhaps  increased  destruc- 
tion of  corpuscles.     There  is  in  this  dis- 
ease   then    a    morbid    cell-activity    that 
tends  to   persist  with  great  pertinacity 
in  the  wrong  direction.    E.  Grawitz  (Ber- 
liner klin.  Woch.,  Aug.  8,  '98). 
Etiology. — Although  the  disease  occa- 
sionally occurs  in  children,  it  is  most 
common  in  adults  between  the  ages  of 
twenty  and  forty  years. 

Males  are  attacked  more  frequently 
than  females,  with  a  slight  difference  in 
favor  of  the  former.    The  disease  is  more 
prevalent  among  the  better  than  in  the 
lower  classes,  and  is  most  common  in 
Europe,  especially  in  Switzerland:    e.g., 
in  regions  in  which  the  people  are  badly 
fed,  and  who  live  in  poorly-ventilated 
and  badly-lighted  houses.     Fright  and 
grief  are  prominent  etiological  factors. 
The  following  group  of  etiological  fac- 
tors has  been   established  in   pernicious 
anfemias:    1.  Gastro-intestinal  disease  of 
long   standing,   poor    food,    impaired   di- 
gestion;   chronic  constipation,  especially 
in  women  frequently  pregnant;    irregular 
defecation  in  women  and  girls,  especially 
those    of    hysterical    temperament.      In 
such  cases  it  is  due  to  intoxication  from 
the  gastro-intestinal  tract.    2.  Pregnancy. 
Here,  too,  probably,  there  is  an  autoin- 
toxication from  the  intestinal  tract,  on 
account  of  pressure  exerted  by  the  gravid 
uterus  on  the  bowel.    3.  Chronic  hsemor- 
rhages,  especially  of  small  size.     4.  Con- 
stitutional   syphilis,    particularly    when 
associated  with  sclerosis  of  the  marrow 


282 


AN.^MIA,  PERNICIOUS.    ETIOLOGY. 


of  the  long  bones.  5.  Bad  hygienic  con- 
ditions of  various  kinds,  especially  In 
the  female  sex;  hard  work,  with  insuffi- 
cient food,  bad  air,  and  emotional  ex- 
citement. In  higher  social  strata  the 
disease  may  be  found  in  women  who  are 
subjected  to  intense  mental  strain  as  the 
result  of  a  desire  to  equal  men  in  phys- 
ical efforts.  Frequent  pregnancy  and 
prolonged  lactation  are  also  factors.  6. 
Chronic  poisoning,  as,  e.g.,  by  carbon 
monoxide.  7.  Bothrioeephalus  and  an- 
chylostomuin — those  eases  belong  here 
that  are  not  cured  after  the  expulsion  of 
the  worms.  E.  Grawitz  (Berliner  klin. 
Woch.,  Aug.  8,  '98). 

Scarcity  of  hsematoblasts  and  loss  of 
contractility  of  blood-clots  are  the  most 
important  signs.  In  severe  ansemia  it  is 
usual  to  find  that  some  nucleated  red 
blood-corpuscles  are  present;  but,  apart 
from  leucocythsemia  and  fi'om  blood  in- 
fections, such  corpuscles  are  not  merely 
scarce,  but  are  also  of  small  size.  Hayem 
(La  Presse  Med.,  Oct.  7,  '99). 

In  110  personal  cases  of  pernicious 
ansemia,  there  were  57  males  and  53  fe- 
males, and  only  four  cases  followed  par- 
turition. Late  middle  life  predisposed  to 
it,  as  shown  by  the  fact  that  in  82  of 
the  eases  the  patients  were  over  40  years 
of  age.  Pernicious  anaemia  is  much  more 
frequent  than  the  text-books  would  lead 
one  to  suppose.  Some  cases  had  pre- 
viously been  diagnosed  as  tuberculosis. 
There  was  very  little,  if  any,  relation 
between  the  menopause  and  pernicious 
anaemia.  It  had  nothing  to  do  with 
syphilis.  Haemorrhage  was  quite  com- 
mon, especially  of  the  nose  and  gums. 
The  striking  constancy  of  the  symptoms 
in  almost  all  eases,  even  in  some  of  the 
so-called  mild  ones,  was  noted,  viz.: 
muscular  weakness,  dyspnoea,  gastro- 
intestinal disturbance  (paroxysmal  diar- 
rhoea) .  The  appetite  was  poor  in  all  but 
three  cases,  and  in  these  it  was  ravenous. 
In  two-thirds  of  the  eases  there  had  been 
a  temperature  of  99°  to  100°  F.,  and 
even  higher.  The  urine  in  53  cases  was 
normal,  while  others  had  had  a  trace  of 
albumin  with  granular  casts.  Nervous 
symptoms  had  not  been  constant.  Some 
cases  had  had  myelitis.  As  to  the  blood, 
the  white  corpuscles  were  subnormal;  the 


number  of  red  corpuscles  was  2,500,000. 
The  diameter  of  the  white  corpuscles  was 
greater  than  normal.  The  proportion  of 
lymphocytes  was  relatively  high.  There 
was  no  relationship  between  the  symp- 
toms and  the  blood  condition.  The  aver- 
age duration  of  this  disease  was  from  one 
to  two  years.  The  longest-lived  case  was 
five  years.  All  treatment  was  hopeless, 
unless  the  use  of  laxatives  would  be  of 
service,  woi-king  along  the  line  of  Hun- 
ter's idea,  that  of  gastro-intestinal  tox- 
Eemia.  Arsenic  did  little,  if  any,  good  in 
these  cases.  R.  C.  Cabot  (Med.  Record, 
May  12,  1900). 

Pregnant  women  represent  the  largest 
proportion  of  cases.  Eepeated  parturi- 
tion is  probably  the  most  prolific  cause 
of  the  disease,  for  it  is  seldom  met  with 
in  primiparse.  Excessive  and  prolonged 
lactation  and  puerperal  hsemorrhages  and 
other  exhausting  conditions  frequently 
appear  as  the  primary  element  in  the 
cairsation  of  the  disease. 

Certain  atrophic  conditions  of  the 
gastric  mucous  membrane,  ulcers  of  the 
stomach,  malaria,  syphilis,  cancer,  and 
alcoholism  have  also  been  considered  as 
etiological  factors. 

Infection  through  solutions  of  con- 
tinuity or  purulent  foci  may  possibly  act 
as  a  primary  cause. 

Intestinal  parasites — the  anchylostoma 
duodenale  and  the  bothrioeephalus  latus 
— are  also  considered  as  possible  etiolog- 
ical factors. 

In  twenty-six  fatal  cases  in  Fiji 
eighteen  found  to  have  anchylostoma  in 
duodenum.  Hirsch  (London  Lancet,  Dec. 
1,  '94). 

Of  t^^•enty-three  native  African  ne- 
groes, representing  various  parts  of  East 
and  West  Africa,  the  following  parasites 
were  found:  Anchylostoma  duodenale, 
twenty-one  times;  trichocephalus  dispar, 
eight  times;  ascaris,  eight  times;  an- 
guillula  stercoralis,  four  times;  taeniae, 
four  times;  amoebae,  twice.  The  tiegroes 
showed  no  sign  of  anmmui, — so  striking 
a   symptom   in  Europeans   with   anchy- 


ANEMIA,  PERNICIOUS.    PATHOLOGY. 


283 


lostomiasis.     Zinn  and  Jacoby   (Bei-liner 
klin.  Woch.,  No.  36,  '96). 

A  severe  form  of  anaemia  due  to 
anehylostomiasis  is  found  among  native 
Egyptians,  in  the  East  and  West  Indies, 
South  America,  and  Europe.  The  promi- 
nent symptoms  of  this  condition  are 
coliclcy  pains,  irregular  bowels  with  oc- 
casional attacks  of  diarrhoea,  nausea, 
and  more  rarely  vomiting.  There  is 
great  weakness  in  some  cases,  with  ema- 
ciation, and  the  circulatory  symptoms 
found  in  the  extreme  anaemias,  dizziness, 
palpitation,  and  hasmic  murmurs  are 
noted.  Eight  cases  of  the  same  kind  re- 
ported in  the  United  States,  in  which  the 
para.site  has  been  identified.  It  may  be 
more  frequent  than  is  believed,  because 
the  intestinal  discharges  are  not  exam- 
ined for  the  parasite,  the  anaemic  con- 
dition being  thus  regarded  as  primary. 
H.  B.  Allyn  and  M.  Behrend  (Amer. 
Med.,  July  13,  1901). 

Pathology. — The  two  prevailing  the- 
ories as  to  the  pathogenesis  of  pernicious 
ansemia  are  the  following:  1.  That  the 
•disease  is  due  to  breaking  up  of  the 
blood-corpuscles  (hsemolysis).  2.  That, 
owing  to  some  defect  in  the  blood-mak- 
ing (htemogenesis),  the  blood  becomes 
vulnerable  to  the  destructive  influence 
■of  micro-organisms. 

Alterations  in  the  size  of  the  heart  in 
ansemio  subjects.  Dilatation  is  com- 
monly met  with,  and  sometimes,  espe- 
cially in  chlorosis,  elevation  of  the  dia- 
phragm displaces  the  heart  upward  and 
an  apparent  dilatation  is  found.  Anaemic 
dilatation  is  to  be  considered  true  idio- 
pathic dilatation  resulting  from  over- 
strain. None  of  the  usual  symptoms  are 
present;  gastralgia  alone  is  complained 
of.  Wybauw  (Jour.  M6d.  de  Brux.,  Mar. 
15,  1900). 

Anaemic  dyspnoea  is  mainly  due  to 
vasomotor  failure;  the  disease  is  preva- 
lent in  the  female  sex,  whose  vasomotor 
system  is  more  unstable  than  that  of  the 
male,  it  usually  occurs  at  puberty  when 
this  system  is  unusually  active.  J.  Hen- 
ton  White  (Birmingham  Med.  Rev.,  Oct., 
1900). 


The  cord  and  nerve  changes  sometimes 
met  with  probably  result  from  the  same 
irritant.  These,  with  the  irregular 
course,  fever,  and  gastro-intestinal  dis- 
turbance, indicate  a  toxic  cause.  The 
general  condition  does  not  seem  to  bear 
any  definite  relation  to  the  blood-state, 
at  least  as  far  as  the  number  of  erythro- 
cytes is  concerned,  for  one  individual 
with  only  1,000,000  per  cubic  millimetre 
may  be  capable  of  prolonged  efforts, 
while  another  with  4,000,0j0  may  be 
weak  and  easily  exhausted.  Weakness, 
then,  is  not  proportionate  to  the  anae- 
mia, is  often  the  earliest  symptom  com- 
plained of,  and  may  precede  the  pallor. 
McPhedran   (Lancet,  Jan.  19,  1902). 

Deficiency  of  red  corpuscles  (oligo- 
cythsemia)  is  always  very  great;  the 
blood  is,  therefore,  pale  and  thin,  resem- 
bling sherry-wine.  The  oligocythasmia 
is  sometimes  so  marked  that  the  normal 
proportion  of  5,000,000  red  corpuscles  to 
the  cubic  millimetre  is  reduced  to  one- 
twenty-fifth  of  that  number.  Quincke 
reported  a  case  in  which  there  were  only 
143,000  to  the  cubic  millimetre  imme- 
diately before  death. 

The  liEemogiobin  is  also  greatly  re- 
duced (oligochromaBmia),  but  not  in 
proportion  with  the  cell-reduction.  The 
haBmogiobin  percentage  was  greater  by 
10  per  cent,  in  a  case  seen  by  Osier. 

Emphasis  upon  the  reduction  in  the 
number  of  the  red  blood-corpuscles. 
There  is  no  disease,  except  pernicious 
anaemia,  in  which  the  number  of  red 
corpuscles  is  at  any  time  reduced  below 
20  per  cent.  This  affords  a  distinction 
between  pernicious  anaemia  and  latent 
gastric  cancer:  a  disease  with  which  the 
former  is  most  likely  to  be  confounded. 

The  relativelj'  high  percentage  of 
haemoglobin  depends  upon  increased  aver- 
age size  of  the  corpuscles  and  in  some 
oases  on  the  presence  of  an  unusual 
number  of  highly  colored  and  minute 
microcytes.  It  also  depends,  in  a  meas- 
ure, upon  the  time  at  which  the  exami- 
nation is  made.  The  icteric  color  of  the 
skin  and  the  dark  urine  are  caused  by 


284 


AN.EMIA,  PERNICIOUS.    PATHOLOGY. 


dissolution  of  the  red  blood-corpuscles, 
and  the  haemoglobin  estimated  at  one  of 
these  periods  will  thus  be  higher,  owing 
to  the  more  highly  colored  plasma.  The 
red  blood-corpuscles  show  marked  signs 
of  reversion  to  the  type  of  blood  which 
is  normal  in  the  cold-blooded  animals. 
F.  P.  Henry  (Amer.  Jour,  of  Med. 
Sciences,  Aug.,  1900). 

Besides  the  above,  there  is  a  species 
of  degeneration  closely  resembling  co- 
agulation-necrosis, and  an  alteration  of 
the  corpuscles,  characterized  by  the  ap- 
pearance in  their  interior  of  one  or  two 
corpuscles  composed  of  modified  haemo- 
globin, — degeneration  hemoglohinemique. 
The  process  of  regeneration  is  mani- 
fested by  the  presence  of  nucleated  red 
corpuscles,  which  are  divided  by  Ehrlich 
into  two  varieties:  the  normoblasts  and 
the  megaloblasts,  the  former  correspond- 
ing to  the  haamatinic  evolution  of  adults, 
the  latter  to  that  of  the  embryo.  The 
nucleus  of  the  normoblast  is  extruded 
to  form  a  new  red  corpuscle,  while  the 
nucleus  of  the  megaloblast  is  absorbed. 

Fresh  blood  shows  nucleated  red  cor- 
puscles of  large  size,  divided  by  Ehrlich 
into  megalocytes  and  gigantocytes. 
Others  are  termed  macrocytes. 

Fiirbringer  has  shown  that  a  case  is 
to  be  considered  as  one  of  true  perni- 
cious anaemia  only  when  one-fourth  of 
the  red  corjDuscles  are  macrocytes. 

The  presence  of  megaloblasts  is  a  sign 
that  certain  pathological  changes  are 
taking  place  in  the  red  marrow  rather 
than  a  distinctive  feature  of  pernicious 
anaemia.  The  macrocytes  and  metrocytes 
are  more  characteristic  of  pernicious 
anaemia,  because  they  are  the  direct  pre- 
cursors of  the  large  red  marrow-cells. 
Engel  (Wiener  med.  Woeh.,  No.  20,  '98). 

By  the  subcutaneous  injection  of  the 
muriate  of  phenylhydrazin  into  animals 
a  condition  of  the  blood  similar  to  that 
in  pernicious  anaemia  is  obtained.  The 
view  that  pernicious  anaemia  is  a  true 
haemoglobinaemia  questioned.     S.   Kami- 


ner    and    E.    Eohnstein     (Berliner    klin. 
Woch.,  July  30,  1900). 

Misshapen  corpuscles  (poikilocytes)  are 
very  frequently  observed,  oftener,  indeed, 
than  in  any  other  afliection. 

Many  small,  imperfectly  developed  cor- 
puscles (mierocytes)  are  generally  found. 

In  marked  cases  corpuscles  endowed 
with  motion  are  occasionally  observed. 

Red  blood-corpuscles  of  normal  blood 
are  motionless.  The  elements  observed 
in  eases  of  high  degree  of  anaemia  are 
endowed  with  four  kinds  of  motion:  1. 
A  movement  of  the  entire  mass  of  the 
corpuscle.  2.  The  projection  of  mobile 
prolongations.  3.  A  movement  of  oscil- 
lation, manifested  slowly  by  minute  cor- 
puscles. 4.  A  movement  which  results 
in  changing  the  position  of  the  cor- 
puscles. These  movable  coi-puscles  are 
bodies  arrested  in  their  evolution  and 
still  retaining  the  contractile  properties 
of  the  haematoblasts  from  which  the  red 
corpuscles  originate.  On  superficial  ex- 
amination they  might  readily  be  mis- 
taken for  parasites.  Hay  em  (La  Mede- 
cine  Moderne,  Feb.  26,  '90). 

[Several  years  ago  I  observed  distinct 
movements  in  the  red  corpuscles  in  a 
case  of  pernicious  anaemia,  but  made  no 
public  mention  of  the  interesting  fact. 
F.  P.  Heney,  Assoc.  Ed.,  Annual,  '91.] 

Large  number  of  amoeboid  corpuscles 
found  in  fresh-blood  preparations,  larger 
than  red  corpuscles,  and  possessed  of 
very  active  movements.  Perles  (Medical 
Press,  June,  '93). 

[In  view  of  the  fact  that  the  red  blood- 
corpuscles  of  pernicious  anaemia  have 
been  observed  by  Hayem  and  others  to 
be  possessed  of  amoeboid  movements,  I 
would  hesitate,  in  the  absence  of  further 
proof,  to  regard  the  bodies  described  by 
Perles  as  other  than  degenerated  blood- 
constituents.  F.  P.  Henry,  Assoc.  Ed., 
Annual,  '94.] 

Small,  mobile  bodies  ob.served,  staining 
the  same  as  red  coi-puscles  and  resem- 
bling fragments  of  haematins,  thought  to 
possess  pathognomonic  value.  Senator 
(Le  Bulletin  Medical,  May  26,  '95). 


AN/EMIA,  PERNICIOUS.    PATHOLOGY. 


285 


study  of  flfty  eases.  Most  typical 
points  in  the  blood:  1.  A  reduction  of 
the  number  of  red  cells  to  about  1,000,- 
000.  2.  The  absence  of  leucocytosis.  3. 
Possibly  a  relatively  high  percentage  of 
hfEmoglobin  in  some  cases.  4.  Increase 
in  average  diameter  of  the  red  cells.  5. 
The  presence  of  large  number  of  poly- 
chromophilic  red  cells.  6.  The  presence 
of  nucleated  red  cells,  a  minority  being 
normoblasts.  7.  The  presence  of  mye- 
locytes. 8.  A  relatively  high  percentage 
of  small  lymphocytes  at  the  expense  of 
the  poljanorphonuclear  cells.  Cabot 
(Boston  Med.  and  Surg.  Jour.,  Aug.  6, 
'96). 

Pernicious  anaemia  is  essentially  a 
htemolytic  disease,  the  haemolysis  being 
due  to  some  as  yet  unknown  poison 
comparable  in  its  effect  on  the  blood 
and  blood-organs  to  the  action  of 
toluylene-diamine — vs'hether  autointoxi- 
cation or  infection  remains  yet  to  be 
determined.  The  poison  of  pernicious 
anaemia  stimulates  the  phagocytes  of 
the  spleen,  lymph-  and  haemolympli- 
glands,  and  bone-marrow  to  increased 
haemolysis  (cellular  haemolysis).  Either 
the  phagocytes  are  directly  stimulated 
to  increased  destruction  of  red  cells  or 
the  latter  are  so  changed  by  the  poison 
that  they  themselves  stimulate  the 
phagocytes.  The  haemoh'sis  of  perni- 
cious anaemia  differs  only  in  degree,  not 
in  kind,  from  normal  haemolysis  or  the 
pathological  increase  occurring  in  sep- 
sis, typhoid,  etc.  It  is  not  improbable 
that  from  the  destruction  of  haemoglo- 
bin poisonous  products  (histon  ?)  may 
be  formed  which  has  also  a  haemolytic 
action;  a  vicious  circle  of  haemolj'sis 
may  thus  be  produced.  Ko  proof  of 
this  exists  at  present.  The  haemolysis 
of  pernicious  anaemia  is  not  confined 
to  the  portal  area,  as  according  to  Hun- 
ter, but  in  some  cases  at  least  takes 
place  also  to  a  large  extent  in  the  pre- 
vertebral lymph-  and  haemolymph-  nodes 
and  bone-marrow.  In  the  majority  of 
eases  the  spleen  is  the  chief  seat  of 
the  blood-destruction.  No  evidences  of 
haemolysis  in  the  liver,  stomach,  and 
intestinal  capillaries  were  found  in  the 
eight  cases.  The  haemosiderin  of  the 
liver   and    kidnevs    is   carried   to    these 


organs  as  some  soluble  derivative  of 
liaemoglobin,  is  removed  from  the  cir- 
culation as  haemosiderin  by  the  en- 
dothelium, and  then  transferred  to  the 
liver-  or  kidney-  cells.  The  deposit  of 
iron  in  these  organs  is  of  the  nature 
of  an  excretion.  In  the  majority  of 
cases  only  slight  reaction  for  iron  is 
found  at  the  sites  of  actual  haemolysis 
(spleen,  Ijonph-  and  haemolymph-  glands, 
and  bone-marrow).  The  greater  part  of 
the  pigment  in  the  phagocytes  of  the 
spleen,  Imyph-  and  haemolymph-  glands 
does  not  give  an  iron  reaction  while  in 
a  diffuse  form.  ^Vhen  changed  to  a 
granular  pigment  the  iron  reaction  may 
usually  be  obtained.  The  change  to 
haemosiderin  is  for  the  gi'eater  part  ac- 
complished by  the  endothelium  of  the 
liver  and  kidneys.  The  varying  path- 
ological conditions  found  in  these  dif- 
ferent cases  of  pernicious  anaemia  can 
be  explained  only  by  a  theory  of  cyclical 
or  intermittent  process  of  haemolysis. 
This  theory  is  also  borne  out  by  the 
exacerbations  so  frequently  seen  clin- 
ically. The  autopsy  findings,  in  so  far 
as  evidences  of  haemolysis  are  concerned, 
Mill  depend  on  the  relation  between  the 
time  of  death  and  the  stage  of  the 
haemolysis.  The  changes  in  the  haem- 
olymph -  glands  found  constantly  in 
these  eight  cases  were:  dilatation  of 
the  blood-sinuses  and  evidences  of  in- 
creased haemolysis,  as  shown  by  the  in- 
creased number  of  phagocytes  contain- 
ing disintegrating  red  cells  and  blood- 
pigment.  In  some  of  the  cases  these 
changes  were  accompanied  by  great  in- 
crease in  size  and  apparent  increase  in 
the  number  of  hasmolj'mph-glands ;  in 
other  cases  there  was  no  hyperplasia, 
the  only  evidence  of  the  changes  present 
being  that  obtained  by  the  microscopical 
examination.  The  changes  found  can- 
not be  regarded  as  a  specific  of  per- 
nicious anemia,  since  it  is  probable 
that  they  may  be  produced  by  other 
infections  or  toxic  processes  character- 
ized by  great  haemolysis.  The  lymphoid 
and  megaloblastic  changes  in  the  bone- 
marrow  do  not  form  an  essential  part 
of  the  pathology  of  pernicious  anaemia, 
and  are  to  be  regarded  as  of  a  com- 
pensatory nature:  an  increased  activity 
of  red-cell  formation  to  supply  the  defi- 


286 


ANEMIA,  PERNICIOUS.    PATHOLOGY. 


ciency  caused  by  the  excessive  hae- 
molysis. A.  S.  Warthin  (Amer.  Jour. 
Med.  Sciences,  Oct.,  1902). 

In  cases  in  which  the  urine  is  dark 
the  latter  is  found  to  contain  patholog- 
ical urobilin:  a  substance  known  to  be 
derived  from  the  disintegration  of  haem- 
oglobin. 

Peculiarity  of  highly  colored  urine  is 
that  it  presents  a  low  specific  gravity, 
averaging  1.014.  Presence  of  patholog- 
ical urobilin  described  by  MacMunn  of 
high  diagnostic  significance.  W.  Hunter 
(Brit.  Med.  Jour.,  July  5,  '90). 

Case  in  which  the  urine,  instead  of 
presenting  the  appearance  upon  which 
so  much  stress  is  justly  laid  by  Hunter, 
was  habitually  pale.  R.  Douglas  Powell 
(Clinical  Journal,  Aug.,  '96). 

The  gastric  and  intestinal  disorders 
are  probably  due  to  the  formation  of  a 
toxin,  which,  in  turn,  acts  as  the  etio- 
logical factor  of  the  general  disease. 

Two  ptomaines — cadaverin  and  pu- 
trescin,  which  are  never  formed  except 
by  the  action  of  micro-organisms — found 
in  the  urine  of  a  case.  They  are  not  the 
result  of  ordinary  putrefactive  changes, 
for,  in  scarlet  fever,  diphtheria,  typhoid 
fever,  and  other  affections  in  which 
putrefactive  processes  in  the  intestines 
are  in  excess,  they  are  absent  from  the 
urine.  They  have  been  found  in  no  other 
condition  but  cystinuria:  three  cases, 
the  first  of  which  was  studied  by 
Udranzky  and  Baumann,  the  last  two  by 
Brieger.  The  presence  of  these  ptomaines 
in  this  case  indicates  the  action  of  special 
micro-organisms  in  its  causation.  W. 
Hunter  (Brit.  Med.  Jour.,  July  5,  12, 
'90). 

The  addition  of  putrid  serum  causing 
normal  blood  to  rapidly  form  haemo- 
globin crystals  suggests  the  probability 
that  the  disease  is  dependent  upon  the 
formation  of  some  poison  or  ferment  as- 
sociated with  micro-organisms.  F.  W. 
Mott  (London  Lancet,  Feb.  8,  '90). 

The  so-called  idiopathic,  or  "crypto- 
genetic,"  varieties  are  probably  due  to 
the  destruction  of  the  red  corpuscles  by 
poisonous  substances :  toxins  or  enzymes 
formed  within  the  bodv  itself  or  intro- 


duced into  it  from  without.  Birch- 
Hirschfeld  (La  Semaine  Medicale,  Apr. 
23,  '92). 

Typical  case  in  which,  although  no 
special  derangement  of  digestion  was 
complained  of,  there  was  found  at  the 
autopsy  a  high  degree  of  atrophy  of  the 
glandular  structure  of  the  stomach  and 
intestines.  Eisenlohr  (Medical  News, 
Apr.  2,  '92). 

It  is  a  question  whether  there  can  be 
any  more  satisfactory  explanation  of 
certain  cases  of  surgical  infection  than 
this  theory  of  the  possible  infection  of 
wounds,  not  from  outside,  but  from  bac- 
teria circulating  in  the  tissues,  which, 
under  normal  conditions,  are  destroyed 
and  rendered  harmless,  but  which  under 
the  abnormal  traumatic  conditions  of 
the  operation  are  now  able  to  pro- 
liferate and  set  up  local  disturbances. 
The  usual  explanation  of  the  abun- 
dant growth  of  bacteria  in  the  vari- 
ous organs  after  death  is  that,  while 
there  may  oftentimes  occur  an  agonal 
invasion  of  bacteria,  the  essential  cause 
of  putrefaction  is  the  entry  of  bacteria, 
more  especially  through  the  intestines 
after  death.  This  explanation  is  based 
on  the  observation  of  large  numbers  of 
intestinal  bacteria  in  the  tissues  about 
ten  hours  after  death.  The  author  be- 
lieves this  appearance  of  post-mortem  in- 
vasion of  the  tissues  is  only  apparent, 
not  a  real  fact ;  it  occurs  because  there  is 
a  preliminary  period  in  which  the  bac- 
tericidal action  of  the  tissues  continues 
and  the  number  of  bacteria  to  be  ob- 
tained from  the  tissues  by  ordinary 
methods  is  singularly  small;  following 
this  there  is  multiplication.  The  ex- 
istence of  a  condition  of  subinfection  is 
considered  probable.  The  Avriter  has 
found  minute  diplococcoid  bodies  pecul- 
iarly frequent  in  the  liver-cells  in  cases  of 
hepatic  cirrhosis.  The  frequency  with 
which  the  colon  bacillus  has  been  found 
by  other  observers,  associated  with  more 
acute  hepatic  disease,  renders  it  not  im- 
possible that  this  bacillus  may  have  some 
part  to  play  in  connection  with  the  con- 
dition. A  careful  study  of  material  from 
cases  of  hsemochromatosis  with  the  high- 
est power  shows  that  when  the  pigment 
has  not  clumped  together  into  too  large 


ANEMIA,  PERNICIOUS.    PATHOLOGY. 


28r 


masses  in  the  liver-cells  for  example,  or 
in  the  abdominal  lymphatic  glands,  there 
are,  in  a  very  large  proportion  of  the 
ultimate  fine  masses  of  ■pigment,  distinct 
diplococcoid  forms  or  bodies.  In  short, 
the  condition  of  hsemochromatosis  is  of 
bacterial  origin.  Anderson,  one  of  the 
writer's  demonstrators,  has  made  a  spe- 
cial study  of  the  bacteriology  of  the 
stomach  in  three  cases  of  pernicious 
anaemia.  He  has  found  in  all  a  complete 
absence  of  hydrochloric  acid,  with  the 
presence,  however,  of  considerable  quan- 
tities of  lactic  and  some  butyric  acid, 
and  in  all  the  eases  he  obtained  by  plat- 
ing pure  cultures  of  the  colon  bacillus, 
and,  what  is  more,  on  making  sections 
from  one  of  the  stomachs  he  found 
numerous  diplococcoid  forms  in  the  sub- 
mucous tissue.  This  was  long  before  the 
nature  of  the  pigment  in  the  liver  had 
been  realized.  In  order  to  confirm  the 
result.  Ford  made  an  independer-t  exam- 
ination in  a  case  at  the  Royal  Victoria 
Hospital,  which  absolutely  confirmed  the 
findings  of  Anderson  in  every  respect. 
J.  George  Adami  (Jour.  Amer.  Med. 
Assoc,  Dec.  23,  '99). 

Carious  teeth  are  seen  extremely  com- 
monly in  this  disease;  inflammation  of 
the  mouth  and  tongue  is  also  exceedingly 
common,  as  are  gastric  symptoms;  the 
gastric  catarrh  is  of  an  infectious  nature 
and  is  dependent  upon  the  caries  of  the 
teeth.  The  original  infection  may  usu- 
ally be  traced  to  the  teeth.  Sometimes 
to  drain  poisons.  Hunter  (Lancet,  Jan. 
27,  1900). 

Case  of  pernicious  anaemia  following 
on  traumatic  stricture  of  the  small  in- 
testine. The  necropsy  confirmed  the 
diagnosis  of  pernicious  anaemia.  The  ex- 
amination of  the  blood  presented  a  typ- 
ical picture  of  that  disease.  The  patient 
had  always  had  bad  teeth,  with  alternate 
alveolar  and  ethmoidal  suppuration,  and 
chronic  gastric  catarrh,  thus  bearing  out 
Hunter's  idea  as  to  pernicious  anaemia 
being  due  to  self-intoxication  from  the 
intestinal  tract.  A.  E.  Barker  (Lancet, 
July  21    IPOO). 

Eighteen  cases  of  bothriocephalus 
latua  anaemia  and  3  of  pernicious  anae- 
mia showed  that,  before  removal  of  the 
worm,  increased  decomposition  of  albu- 


min was  present,  while  after  removal  of 
the  parasite  albuminous  metabolism  was 
not  as  greatly  affected.  Decomposition 
of  albumin  is  probably  due  to  some 
toxin  produced  by  the  worm.  E.  Rosen- 
quist  (Berliner  klin.  Woch.,  June  24, 
1901). 

Conclusions  regarding  the  enteroge- 
nous origin  of  pernicious  anaemia  from 
experiments  performed  on  metabolism 
are  not  tenable  because  we  do  not  al- 
ways know  under  what  form  of  diet  the 
disease  occurs.  Personal  disposition 
must  be  taken  into  consideration. 
Many  theories  are  exaggerated;  the 
symptoms  present  in  pernicious  anaemia, 
frequently  exist  without  serious  blood- 
changes  being  present.  E.  Grawitz  (Ber- 
liner klin.  Woch.,  June  17,  1901). 

The  spleen  is  generally  thought  to  pre- 
sent no  characteristic  lesion,  although 
the  amount  of  iron  in  it  is  usually  in- 
creased. 

Case  in  which  there  was,  besides  severe 
haemolysis,  sclerosis  of  the  spleen  and. 
pancreas,  with  marked  changes  in  the 
suprarenal  capsules.  Douglas  Stanley 
(Brit.  Med.  Jour.,  Feb.  16,  '95). 

Case  in  which  a  microscopical  exami- 
nation of  the  spleen  showed  no  increase- 
of  connective  tissue  and  a  marked 
diminution  of  cellular  elements,  both  of 
the  Malpighian  bodies  and  of  the  spleen 
pulp.  In  many  of  the  Malpighian  bodies 
the  small,  round  cells  were  entirely  want- 
ing. A  slight  reaction  for  iron,  haemo- 
siderin,  was  developed  by  potassium 
ferrocyanide  and  acidified  glycerin,  but 
it  was  much  less  marked  than  in  the 
liver.  There  was  no  granular  pigment 
observed  as  a  result  of  the  extensive  de- 
struction of  the  red  blood-cells.  James 
Ewing    (Med.   Record,  Sept.  5,  '96). 

Case  in  which  the  total  quantity  of 
iron  found  in  the  liver  was  0.2433  per 
cent,  by  weight  calculated  to  the  fresh 
undried  tissue.  This  is  equivalent  to- 
about  0.72  per  cent,  in  the  dried  tissue. 
The  estimation  accords  fully  with  the 
observations  of  previous  observers,  as 
showing  the  very  great  increase  in  the 
iron  contained  in  the  liver  in  this  disease. 
E.  F.  Euttan  and  J.  G.  Adami  (Brit. 
Med.  Jour.,  Dec.  12,  '96). 


288 


ANEMIA,  PERNICIOUS.    PATHOLOGY. 


The  jaundice  is  probably  due  to  accu- 
mulation of  iron  in  the  hepatic  system. 

Fatal  C£Lse  of  pernicious  anaemia  in  a 
woman  aged  49.  Chemical  examination 
of  liver,  spleen,  and  kidney  showing  that 
the  liver  contained  a  large  proportion  of 
iron  in  the  ferric  state,  while  the  spleen 
was  free  from  iron  in  appreciable 
amount.  F.  W.  Mott  (London  Lancet, 
Feb.  8,  '90). 

Autopsy  of  a  case.  Iron  reaction  well 
marked  in  liver  and  kidneys,  but  absent 
in  spleen;  the  amount  of  iron  in  the 
liver  found  by  quantitive  analysis  to  be 
five  times  greater  than  normal.  T.  N. 
Kelynack  and  F.  J.  H.  Coutts  (Medical 
Chronicle,  Sept.,  '92). 

Inquiry  into  the  after-history  of  22 
cases.  Tlie  disease  believed  to  be  due  to 
an  increase  in  the  destructive  action  of 
the  liver  upon  the  red  blood-corpuscles. 
While  the  22  cases  were  thought  to  be 
"cured"  by  various  means,  10  died  of  the 
disease,  and  only  2  were  known  to  be 
living  at  the  time  of  the  investigation. 
H.  C.  Colman  (Edinburgh  Med.  Jour., 
Mar.  and  Apr.,  1901). 

The  posterior  and  lateral  spinal  tracts 
present  changes  resembling  those  ob- 
served in  tabes. 

Study  of  seventeen  eases.  The  degree 
of  nervous  affection  not  necessarily  pro- 
portionate to  the  degree  of  anaemia.  In 
pernicious  anaemia  any  of  the  spinal 
symptoms  of  tabes  may  be  present,  while 
symptoms  entirely  foreign  to  tabes  may 
also  occur.  Diseased  centres  in  any  por- 
tion of  white  substance,  preferably  in 
posterior  columns;  gray  substance,  zone 
of  Lissauer,  and  intermedullary  roots  re- 
main unaffected.  Nonne  (Deutsche  Zeit- 
schrift  filr  Nervenh.,  vol.  v). 

Microscopical  appearances  of  brain  in  a 
case:  haemorrhages  in  the  substance  of 
the  hemispheres;  round,  structureless 
bodies,  resembling  corpora  amylacea,  ar- 
ranged in  groups;  fatty  degeneration  of 
the  cells  of  the  motor  region;  shrinkage 
and  vacuolation  of  the  cells  of  Purkinje. 
Biruli  (St.  Petersburger  med.  Woch., 
June  30,  '94). 

In  nine  cases  localization  of  centres 
found  to  be  the  same  as  that  given  by 


others, — Nonne,  for  instance.  A  primary 
and  possibly  toxic  affection  of  the  nerve- 
fibres  supposed.  C.  W.  Burr  (University 
Med.  Mag.,  Apr.,  '95). 

Three  cases  of  pernicious  anaemia  with 
spinal-cord  symptoms,  one  ending  fatally 
after  several  weeks.  Angel  Money  (Aus- 
tralasian Medical  Gazette,  June  15,  '95). 

Changes  in  spinal  cord  similar  to  those 
met  with  in  pernicious  anaemia  may 
occur  in  a  variety  of  other  diseases,  com- 
bined with  cachexia  and  marasmus,  Ad- 
dison's disease,  diabetes,  etc.  W.  Miiller 
(Berichte  der  24  deutscher  Chirurgentag, 
'95). 

Case  with  arteriosclerosis,  parsesthesia, 
chronic  enteritis,  and  increased  knee-jerk. 
Small  haemorrhages  found  post-mortem 
in  the  corpora  striata  and  corpora  quad- 
rigemina.  Microscopical  examination 
showed,  besides  changes  described  by 
others  in  the  posterior  columns,  haemor- 
rhages in  both  the  gray  and  white 
matter,  with  degeneration  in  the  anterior 
and  lateral  columns  of  the  cord.  The 
change  in  the  gray  matter  is  of  chief 
importance  in  this  disease.  Teichmiiller 
(Deutsche  Zeitsch.  filr  Nervenheilkunde, 
B.  8,  H.  5,  6,  '96). 

Study  of  nine  cases:  small  haemor- 
rhages and  consecutive  sclerosis  are  fre- 
quently met  with  in  the  spinal  marrow. 
These  haemorrhages  have  no  significance 
from  a  clinical  point  of  view.  The 
vessels  often  show  thickening  and  com- 
mencing hyaline  degeneration  (not,  how- 
ever, as  a  rule) ,  combined  with  degenera- 
tion of  the  nervous  elements.  From  a 
study  of  the  literature  it  appears  that 
comparatively  few  cases  of  pernicious 
anaemia  present  a  real  disease  of  the 
spinal  cord.  The  symptoms  of  anaemia 
remain  unchanged  in  cases  in  which  it 
does  occur,  and  it  is  difficult  to  explain 
why  the  cord  should  be  affected  in  some 
cases  and  not  in  others.  The  disease  of 
the  cord  manifests  itself  witli  somewhat 
varying  symptoms,  certain  of  which, 
however,  are  exhibited  in  all  eases. 
From  an  anatomical  point  of  view  the 
alterations  have  considerable  variations; 
but  this  is  accounted  for,  to  a  great  ex- 
tent, by  the  fact  that  the  process  has 
been  observed  at  a  different  stage  in  the 


ANEMIA,  PERNICIOUS.     PATHOLOGY. 


289 


various  cases.  From  a  closer  analysis  of 
the  cases  it  appears  that  the  degenera- 
tion progresses  in  a  fairl.y  regular  man- 
ner. It  is  presumable  that  these  cases  of 
disease  of  the  spinal  cord  form  a  special 
group,  even  from  a  neurological  point  of 
view.  It  may  be  admitted  that  some 
toxic  condition  is  the  common,  immediate 
cause  of  the  disease  of  the  spinal  marrow 
as  well  as  of  the  anaemia.  The  altera- 
tions of  the  spinal  cord  are  here  wholly 
diflferent  from  those  found  in  tuberculo- 
sis and  diabetes,  where  the  changes  can 
easily  be  distinguished  by  slightly- 
marked  and  chronic  degeneration,  such 
as  is  often  found  in  Addison's  disease. 
Charles  Petren  (Inaugural  Dissertation, 
Stockholm;  Universal  Medical  Journal, 
Feb.,  '96). 

Evidence  showing  that  extensive 
changes  may  be  present  in  the  cord  in 
cases  of  pernicious  anaemia  without  any 
marked  clinical  symptoms,  and  that  the 
lesions  are  of  somewhat  diverse  charac- 
ter. Whether  the  degenerations  of  sys- 
temic tracts  depend  on  haemorrhagic  or 
myelitic  foci  in  all  cases  there  seems 
hardly  yet  sufficient  evidence  to  show; 
the  predominant  affection  of  the  pos- 
terior columns  in  the  majority  of  cases, 
and  their  degeneration  throughout  the 
whole  length  of  the  cord  on  both  sides, 
rather  point  to  an  independent  affection 
of  these  tracts.  J.  Miohell  Clarke  (Brit. 
Med.  Jour.,  Aug.  7,  '97). 

In  cases  of  pernicious  anaemia  the  de- 
generative changes  in  the  cord  sometimes 
observed  are  not  the  result  of  mere  anae- 
mia, but  are  more  probably  the  result  of 
hitherto  undiscovered  chemical  agents. 
A  thorough  examination  of  the  metab- 
olism in  pernicious  anaemia  might,  per- 
haps, throw  further  light  on  the  question. 
G.  von  Voss  (Deutsche  Arch.  f.  klin. 
Med.,  vol.  Iviii,  p.  489,  '97). 

Study  of  pathological  lesions  found  in 
the  spinal  cord  in  cases  of  pernicious 
anaemia  showed  that  there  was  usually 
a  degeneration  affecting  the  posterior 
columns,  sometimes  the  posterior  and 
lateral  together,  but  never  the  lateral 
alone.  This  degeneration  was  chiefly  in 
the  nerve-fibres,  and  was  unaccompanied 
by  shrinking  of  the  cord,  such  as  was 
seen    in   locomotor    ataxia.      Seventeen 

1- 


cases  analyzed  in  which  initial  nervous 
symptom  was  always  a  persistent  parses- 
thesia,  usually  of  the  foot,  associated 
with  some  weakness.  This  was  generally 
followed  quickly  by  ataxia  and  loss  of 
motor  power,  and  severe  pains  in  the 
back  and  limbs  were  not  uncommon. 
The  disease  progressed  rather  rapidly,  so 
that  often  within  one  or  two  months  the 
symptoms  were  well  developed.  In  from 
si.x  months  to  a  year  the  progress  com- 
monly reached  its  acme,  and  during  this 
time  the  anaemia  became  marked.  After 
a  time  the  control  of  the  bladder  and 
the  rectum  was  lost  and  in  fatal  cases 
death  occurred  in  from  six  months  to 
two  years.  The  essential  nature  of  the 
process  was  a  primary  nerve-degenera- 
tion affecting  the  neuraxons  first,  par- 
ticularly in  the  columns  of  Goll  and 
the  crossed  pyramidal  tract.  The  same 
poison  which  caused  pernicious  anaemia 
was  responsible  for  this  disease.  It  usu- 
ally developed  between  the  ages  of  50 
and  60  years,  and  followed  the  acute 
infections,  prolonged  diarrhoeal  or  dysen- 
teric attacks,  lead  poisoning,  malarial 
infection,  etc.  In  10  per  cent,  or  more 
of  the  cases  pernicious  anaemia  un- 
doubtedly co-existed.  Charles  L.  Dana 
(N.  Y.  Med.  Jour.,  Nov.  19,  '98). 

Examination  of  the  spinal  cord  in 
cases  of  pernicious  anaemia  by  the 
Marehi  method.  Resvilts  summarized  as 
follows:  (1)  the  changes  in  the  spinal 
cord  in  fatal  cases  of  anaemia  are  not 
systematic,  but  should  be  regarded  as 
acute  disseminated  myelitis;  (2)  the 
foci  exhibit  a  local  association  with  the 
blood-vessels;  (3)  it  is  probable  that  a 
noxious  material  is  carried  to  the  cord 
by  the  blood-vessels,  and  this  acts  upon 
the  nervous  tissue;  similar  changes  are 
found  in  old  age;  (4)  even  in  advanced 
cases  the  gray  matter  may  escape  in- 
volvement; (.5)  if  diseased,  it  is  not  pri- 
marily affected^ — that  is  to  say,  it  and 
the  white  matter  are  involved  as  the  re- 
sult of  a  single  cause;  (6)  the  diffuse 
character  of  the  degeneration  in  these 
conditions  justifies  the  conclusion  that 
there  is  a  trophic  alteration,  and  not  a 
functional  injury  of  the  nervous  element: 
(7)  the  greater  part  of  degenerated 
fibres  are  found   in  the   posterior   roots 


290 


ANJJMIA,  PERNICIOUS.    PATHOLOGY. 


and  the  anterior  commissure.  Nonne 
(Dent.  Zeits.  f.  Nervenheilk.,  Mar.  9, 
'99). 

Case  of  combined  sclerosis  of  Lielit- 
heim-Putnam-Dana  type  accompanying 
pernicious  antemia.  Tlie  condition 
thought  to  be  a  primary  sj'stemic  de- 
generation dependent  upon  the  perni- 
cious antemia.  Brown,  Langdon,  and 
Wolfstein  (Jour.  Amer.  Med.  Assoc, 
Mar.  2,  1901). 

There  is  a  well-established  relation 
of  diffuse  cord  degeneration  with  per- 
nicious aneemia.  In  seems  highly  prob- 
able that  the  haemolysis  and  the  cord- 
changes  are  due  to  the  same  toxin. 
While  the  source  of  the  toxin  is  un- 
known, the  fact  that  gastro-intestinal 
disturbance  is  so  common  in  the  disease 
would  lead  one  to  suppose  that  it  is 
of  intestinal  origin.  The  diffuse  de- 
generations of  the  spinal  cord  which 
occur  in  conditions  without  pernicious 
anaemia  do  not  appear  to  differ  essen- 
tially from  those  of  pernicious  auEemia. 
It  is  possible  that  a  common  blood- 
circulating  poison  exists,  which  may 
expend  its  force  upon  the  blood  in  one 
individual,  upon  the  nervous  apparatus 
in  another,  and  coincidently  upon  the 
blood  and  spinal  cord  in  others.  Fi-ank 
Billings  (Boston  Med.  and  Surg.  Jour., 
Aug.  28  and  Sept.  4,  1902). 

The  bone-marrow  usually  presents 
changes.  Those  most  frequently  found, 
according  to  Muir,  are  (a)  increased  num- 
ber of  nucleated  red  corpuscles  in  the 
marrow;  (6)  transformation  of  the  fatty 
marrow  in  the  shafts  of  the  long  bones 
into  red  marrow;  (c)  absorption  of  the 
bone-trabeculEe  between  the  red  marrow. 


Bone-marrow  of  a  case  com] 
mainly  of  hsematoblasts.  Normally,  the 
formation  of  red  corpuscles  is  probably 
due  to  the  constricting  off,  from  the  nu- 
cleus, of  the  hajmatoblast  of  protoplasm, 
colored  with  hasmoglobin.  In  pernicious 
ansemia  this  process  does  not  take  place. 
Rindfleisch  (Virchow's  Archiv  fiir  path- 
ologische  Anatomic,  B.  121,  p.  176,  '91). 

Autopsy  showing  that  the  marrow  had 


returned    to    the    foetal    condition.      A. 
Pineau  (La  France  Med.,  Mar.  II,  '92). 

From  the  point  of  view  of  the  function 
of  the  bone-marrow,  three  types  of  per- 
nicious ansemia  may  be  made:  (1)  cas«s 
without  any  reaction  on  the  part  of  the 
bone-marrow;  (2)  those  in  which  the 
reaction  is  insufficient;  (3)  those  in 
which  there  is  a  degeneration  of  the 
bone-marrow,  on  account  of  which  it  fur- 
nishes almost  exclusively  disintegrating 
megaloblasts.  The  condition  of  the  blood 
is  not  always  an  evidence  of  the  changes 
taking  place  in  the  bone-marrow.  The 
percolation  of  the  bone-marrow  seems 
not  to  occur  in  a  uniform  manner,  that 
it  does  not  seem  to  affect  all  the  elements 
in  the  same  way.  Neusser  (Wiener  klin. 
Woch.,  Apr.  13,  '9^). 

Five  cases  of  grave  anaemia  in  which 
the  bone-marrow  apparently  had  lost  its 
power  of  forming  red  corpuscles  at  a 
comparatively  early  period,  as  the  exam- 
ination of  the  blood  showed  no  nucleated 
or  polyehromatophilic  red  corpuscles. 
An  absence  of  nucleated  red  corpuscles 
in  the  blood  in  cases  of  grave  anaemia 
indicates  that  there  is  no  new  formation 
of  red  coi-puscles  taking  place.  The  prog- 
nosis for  such  cases  is  extremely  bad. 
When  the  number  of  red  corpuscles  is 
above  1,500,000  per  cubic  millimetre,  the 
presence  or  absence  of  nucleated  red 
corpuscles  is  of  little  significance ;  but, 
when  they  are  below  that  number  and 
nucleated  red  corpuscles  are  absent,  a 
fatal  result  may  be  confidently  pre- 
dicted. J.  S.  Billings  (N.  Y.  Med  Jour., 
May  20,  '99). 

The  albuminoid  constituent  of  the  or- 
ganism may  be  at  fault. 

Fatal  case  in  which  examination  of  the- 
blood-serum  showed  that  the  proteids  of 
the  plasma  were  altered  in  their  respect- 
ive proportions.  Adami  (Montreal  Med. 
Jour.,  Aug.,  '93). 

Analysis  of  the  blood-serum  removed 
from  the  right  heart:  it  was  clear,  al- 
most colorless,  had  a  specific  gravity  of 
1026.1.  This  is  below  the  figure  usually 
given  as  being  that  of  the  specific  gravity 
of  serum,  namely:    1027  to  1030.    It  con- 


AN.EMIA,  PERNICIOUS.     PROGNOSIS.     TREATMENT. 


291 


tained  only  5.2  per  cent,  of  proteids  (by 
weight).  These  proteids  consisted  of  2.3 
per  cent,  of  globulins  precipitated  by 
saturation  with  magnesium  sulphate,  and 
2.9  per  cent,  of  serum-albumin  proper. 
There  was  0.875  per  cent,  of  ash.  It  will 
thus  be  seen  that  not  only  were  the  total 
proteids  reduced  about  40  per  cent,  below 
the  average  normal  quantity,  but  also 
that  the  normal  ratio  of  the  globulins  to 
the  serum-albumin  was  considerably  al- 
tered; the  ash,  also,  was  about  I2,'/2  per 
cent,  above  the  normal.  R.  F.  Ruttan 
and  J.  G.  Adami  (Brit.  Med.  Jour.,  Dec. 
12,  '96). 

As  ill  understood  as  the  etiology  of 
the  disease  is  the  actual  condition  of  the 
blood.  The  microscopical  appearances 
are  well  known,  but  the  true  chemical 
changes  have  almost  entirely  been  neg- 
lected. The  blood  in  pernicious  aniemia 
contains  a  larger  quantity  of  water  than 
normal  blood,  a  smaller  quantity  of 
solids,  a  higher  proportion  of  chlorine, 
and  a  lower  proportion  of  potassium, 
iron,  and  fat.  There  is  not  sufficient  so- 
dium to  hold  the  chlorine  fixed,  and  the 
potassium  is  also  deficient.  In  various 
tissues  the  proportion  of  water  was 
higher  than  normal  in  the  heart,  and 
lower  in  the  liver,  spleen,  and  brain. 
Treatment  of  pernicious  anaemia  with 
potassium  carbonate,  tartrate,  and  cit- 
rate, in  four  cases,  three  of  which  were 
dying,  resulted  in  recovery.  Th.  Rumpf 
(Berliner  klin.  Woch.,  May  6,  1901). 

The  disease  may  be  due  to  some 
hitherto  undiscovered  organism. 

Two  cases  in  which  5-milligramme  in- 
jections of  sublimate  daily  for  the  space 
of  two  months  were  followed  by  rapid 
improvement.  Patera  (Riforma  Medica, 
May  23,  '96). 

The  causes  of  the  disease  are  of  a 
complex  nature.  Some  cases  present  no 
appreciable  lesions. 

Case  in  which  death  occurred  from 
gradual  asthenia.  Entire  absence  of  or- 
ganic disease  in  all  the  organs  examined ; 
blood-count  gave  1,600,000  red  corpuscles 
per  cubic  millimetre  (32  per  cent.),  while 


haemoglobin  amounted  to  16  per  cent. 
J.  H.  Musser  (University  Med.  Magazine, 
July,  '93) . 

[A  disproportion  of  this  kind  is  cer- 
tainly unusual  in  pernicious  anaemia. 
F.  P.  Henby,  Assoc.  Ed.,  Annual,  '94.] 

A  high  degree  of  ansemia  usually  fol- 
lows numerous  predisposing  causes.  In 
some  it  tends  to  cause  degenerative 
changes  in  vessels,  leading,  in  turn,  to 
capillary  haemorrhages,  conferring  per- 
nicious character.  R.  Stockman  (Brit. 
Med.  Jour.,  May  4,  '95). 

[I  have  for  many  years  maintained 
that  the  arguments  in  favor  of  the  "idio- 
pathic" nature  of  pernicious  anaemia  are 
very  faulty.  F.  P.  Henry,  Assoc.  Ed., 
Annual,  '96.] 

Prognosis. — The  mortality,  from  very 
nearly  100  per  cent.,  has  been  greatly  re- 
duced since  the  introduction,  by  Byrom 
Bramwell,  of  Edinburgh,  of  arsenic.  A 
guarded  prognosis  should  always  be 
given,  however,  relapses  being  exceed- 
ingly common.  About  one-half  of  the 
fatal  cases  last  from  one  to  six  months; 
the  remaining  seldom  reach  beyond  the 
second  year. 

In  attempting  to  reach  a  decision  as 
to  the  efficacy  of  any  plan  pursued  in 
the  treatment  of  pernicious  anaemia,  it 
is  to  be  borne  in  mind  that  periods  of 
transitory  improvement,  of  varying  dura- 
tion, are  often  a  part  of  the  natural 
course  of  the  disease;  so  that  too  much 
importance  must  not  be  attached  to  the 
favorable  results  that  may  follow  the 
special  line  of  medication  employed. 
Even  if  such  improvement  continue  for 
a  long  time,  the  conclusion  must  not  be 
too  hastily  reached  that  the  disease  is 
cured.  Editorial  (Med.  Record,  Nov.  14, 
'96). 

Treatment.  —  Arsenic  cures  the  cur- 
able cases  and  benefits  the  others.  Iron 
is  worse  than  xiseless,  having  shown  it- 
self injurious  in  several  cases  reported. 
Fowler's  solution  may  be  given  in  3- 
minim  doses  three  times  a  day,  increased 


292 


ANEMIA,  PERNICIOUS.    TREATMENT. 


by  1  minim  daily  until  30  minims  are 
taken  after  each  meal,  provided  the 
stomach  do€S  not  rebel,  which  is  seldom 
the  case.  The  patient  should  be  watched 
and  the  drug  reduced  or  discontinued 
temporarily  on  the  appearance  of  any 
of  the  physiological  effects  of  arsenic: 
cedema  of  the  lids,  etc. 

Arsenic  is  as  much  of  a  specific  in  per- 
nicious ansemia  as  mercury  is  in  syphilis. 
Warfvinge  (Transactions  of  the  Eleventh 
International  Medical  Congress,  '94). 

Iron  produces  no  permanent  benefit. 

Acid  preparations  of  phosphorus  exert 
a  temporary  tonic  effect. 

Intestinal  antiseptics,  advocated  by 
Hunter,  only  of  use  in  eases  complicated 
by  gastro-enteric  fermentations. 

Alcohol  (that  is,  distilled  liquors)  does 
no  good;  malt  liquors — ale  or  beer — if 
borne  well,  retard  progress  of  disease. 

Arsenic,  when  tolerated  in  heroic  doses, 
is  very  beneficial,  but  no  permanent 
cures  have  been  authenticated.  I.  N. 
Danforth  (Boston  Med.  and  Surg.  Jour., 
June  25,  '96). 

Case,  which  came  under  observation  in 
1892,  of  a  man  whose  blood  showed  only 
1,600,000  red  corpuscles  to  the  cubic 
millimetre.  Under  arsenic  the  red  cor- 
puscles rose  to  4,000,000  and  the  man 
was  practically  well.  In  1893  he  re- 
lapsed, and  on  ascending  doses  of  Fow- 
ler's solution  he  improved  and  went  back 
to  work  as  roller  in  a  rolling-mill.  In 
the  following  year  he  returned  to  the 
hospital  in  a  worse  condition  than  pre- 
viously. Again,  on  arsenic  he  improved. 
Now,  two  years  later,  he  is  large  and 
portly,  weighing  250  pounds.  His  haemo- 
globin is  90  per  cent,  and  blood-corpuscles 
4,800,000.  M.  H.  Fussell  (Boston  Med. 
and  Surg.  Jour.,  June  25,  '96). 

Marked  case  (mentioned  under  Pa- 
thology) in  which  large  doses  of  arsenic 
(for  several  days  the  patient  took  no 
less  than  from  50  to  60  minims  of  Fow- 
ler's solution  in  the  twenty-four  hours) 
caused  remarkably  rapid  recovery.  The 
condition  of  the  blood  improved  and  the 
jaundice  removed  along  with  other  symp- 
toms. 


Table  Showing  the  Condition  of  the  Blood  and  Dose  of 
Arsenic  at  Different  Dates. 


Date. 

i  i 
is 

|^P.i 

May  5th 
May  lObh 
May  16tli 
May  20th 
May  23d 
May  26th 

810.000 

970.000 

1,710,000 

20 
28 
40 

S 
46 
64 
64 

88 

13,000 
12,000 

50  minims. 
60  minima. 
40  minima. 
40  minima. 
40  minima. 
40  minima. 

2.650,000 
2.9.50.000 
2,700,000 
3,420.000 
4,010,000 

Juna  14th 
July  20th 

12,000 
14,000 

Byrom  Bramwell  (Lancet,  July  24,  '97). 

At  least  two  years  should  elapse  before 
a  patient  is  reported  cured.  Patient  who 
has  been  cured  of  pernicious  ansemia  for 
the  space  of  two  years  by  the  use  of 
arsenic  pushed  to  the  point  of  tolerance. 
The  gentleman  now  an  active  business- 
man. F.  P.  Henry  (Boston  Med.  and 
Surg.  Jour.,  June  25,  '90). 

There  is  no  specific  remedy  for  per- 
nicious ansemia.  Rest  in  bed  is  one  of 
the  first  requisites,  the  assimilation  of 
food  must  be  stimulated.  Lavage  of  the 
stomach,  intestinal  irrigation,  and  saline 
laxatives  are  useful.  In  rare  eases  with 
diarrhoea,  calomel  may  first  be  given; 
later  astringents,  such  as  tannin.  If  the 
urine  contain  much  indiean  intestinal 
antiseptics  are  indicated.  Iron  is  of  no 
value,  and  in  the  beginning  is  contra- 
indicated.  Arsenic  is  the  best  remedy; 
can  be  given  with  quinine.  Inhalations 
of  oxygen  have  been  employed  with  ad- 
vantage. Massage  and  gymnastic  exer- 
cises are  often  of  service.  After  apparent 
recovery  the  patient  must  be  carefully 
observed,  as  relapses  are  likely  to  occur, 
particularly  if  the  hygienic  and  dietetic 
conditions  are  unfavorable.  E.  Grawitz 
(Berliner  klin.  Woch.,  Aug.  15,  '98). 

When  the  gastric  disorder,  which  is 
a  usual  symptom,  prevents  the  admin- 
istration of  arsenic,  the  latter  may  be 
given  subcutaneously,  while  the  stomach 
is  treated  directly  by  lavage. 

An  excess  of  hydrochloric  acid  is  not 
uncommonly  found  in  the  gastric  secre- 
tions. In  such  cases  See  recommends 
an   almost   exclusive   diet   of   meat   and 


AN./EMIA,  PERNICIOUS.     TREATMENT. 


293 


other  albuminous  foods:    raw  meat  to 
the  extent  of  10  to  12  ounces  daily. 

Bone-marrow  sometimes  proves  cura- 
tive. 

Case  successfully  treated  with  bone- 
marrow,  uncooked,  3  ounces  daily.  In  a 
ease  in  which  the  prolonged  administra- 
tion of  iron  and  arsenic  in  both  medium 
and  large  doses  was  proved  useless. 
Thomas  R.  Fraser  (Brit.  Med.  Jour., 
June  2,  '94). 

The  plain  marrow  cannot  always  be 
administered  on  account  of  the  abjection 
of  the  patients.  The  red  marrow  from 
the  tibia  of  the  calf,  mixed  with  an  equal 
quantity  of  glycerin  and  rubbed  up  in  a 
mortar,  results  in  a  preparation  of  pleas- 
ant taste  and  one  that  can  be  eaten  with 
bread  without  disturbing  the  stomach. 
The  preparation  may  be  made  more  fluid 
by  the  addition  of  claret  or  port  wine. 
Alfred  Stengel  (Therapeutic  Gazette,  No. 
13,  '96). 

Severe  case  of  pernicious  anaemia,  com- 
plicated with  oedema,  ascites,  and  cardiac 
symptoms;  2  Vi-ounce  doses  of  fresh 
bone-marrow  administered  daily  in  soup 
or  on  bread.  The  patient  was  cured  in 
two  and  a  half  months.  Blumenau 
(Pediatrics,  June  15,  '97). 

(See  also  Animal  Extracts.) 

In  pernicious  anaemia  bone-marrow  is 
not  by  any  means  of  constant  value. 
Such  cases  with  large  doses  of  iron  and 
arsenic  do  very  often  improve.  But 
herein  lies  the  difference  clinically  be- 
tween simple  and  malignant  antemia:  in 
the  former  complete  cure  results,  but 
with  tendency  to  relapse,  when  the  case 
is  appropriately  treated.  In  the  latter, 
at  the  best  some  improvement  occurs. 
The  amount  of  h.-emoglobin  increases, 
but  does  not  attain  the  normal,  and  in 
no  long  time  the  patient  is  as  bad  as 
ever.  T.  G.  Stewart  (Clinical  Journal, 
Sept.  14,  '98). 

Transfusion  of  blood  should  be  re- 
sorted to  when  improvement  does  not 
follow  the  administration  of  arsenic. 

Transfusion  of  blood  recommended. 
Blood  a  very  indigestible  substance.  The 
practice    of    drinking    it    at    slaughter- 


houses is  not  to  be  commended.  Laache 
(Wiener  klin.  Woch.,  Sept.  18,  '89). 

Case  treated  successfully  by  trans- 
fusion of  blood  defibrinated  and  mingled 
with  a  2-per-cent.  solution  of  phosphate 
of  sodium  in  the  proportion  of  5  '/j 
ounces  of  the  former  to  3  ounces  of  the 
latter.  W.  G.  Evans  (London  Lancet, 
May  13,  '94). 

[Transfusion  should  never  be  omitted 
if  improvement  does  not  follow  the  free 
use  of  arsenic.  The  best  method  is  that 
employed  by  Brakenridge,  of  Edinburgh 
(Edinburgh  Med.  Journal,  Oct.,  '92). 
The  blood  is  kept  fluid  by  admixture 
with  one-third  part  of  its  bulk  of  a  1-to- 
20  (5  per  cent.)  solution  of  phosphate  of 
soda  in  distilled  water  kept  at  blood- 
heat.  John  Duncan,  who  performed  the 
transfusions  in  Brakenridge's  eases,  in- 
sists upon  the  necessity  of  slowness  in 
operating.  He  regards  thirty  minutes  as 
the  minimum  time  that  should  be  occu- 
pied in  injecting  8  ounces  of  the  fluid. — 
F.  P.  Henry,  Assoc.  Ed.,  Annual,  '94.] 

Defibrinated  blood  has  been  used  sub- 
cutaneously  by  Westphalen,  with  success. 

Suhcittaneous  injections  of  normal 
saline  solution  may  replace  transfusion. 

Case  of  a  man,  aged  55  years,  in  whom 
blood-count  showed  480,000  per  cubic 
millimetre;  hsemoglobin,  20  per  cent. 
There  was  delirium,  vomiting,  and  diar- 
rhcea.  Treatment  by  subcutaneous  injec- 
tions of  normal,  saline  solution  on  every 
alternate  day,  and  the  intervening  by 
saline  enemata,  with  arsenic  internally. 
Patient  practically  well.  Alexander  Mc- 
Phedran   (Canadian  Pract.,  Nov.,  '97). 

Protonuclein  seems  to  possess  curative 
properties. 

Marked  case  in  which  protonuclein 
was  used  as  a  last  resort.  A  3-grain 
tablet  ordered  to  be  taken  every  three 
hours  and  all  other  remedies  suspended. 
Two  days  later  kidneys  were  acting  more 
freely,  but  patient's  condition  otherwise 
unchanged.  The  tablets  then  given  every 
two  hours.  Three  days  later  very  de- 
cided improvement.  The  kidneys  were 
acting  freely,  skin  moist,  cedema  passing 
away,    and    a   decided   gain    in    general. 


394 


ANEMIA,  PERNICIOUS. 


ANALGEN. 


Improvement  continued  several  weeks, 
after  which  the  treatment  was  altered, 
the  tablets  being  taken  every  three 
hours,  together  with  V20  grain  arsenous 
acid  thrice  daily.  Recovery.  R.  P. 
Beggs  (Amer.  Medico-Surg.  Bull.,  Dec.  19, 
'96). 
Intestinal  antiseptics  have  been  rec- 
ommended. 

The  best  intestinal  antiseptic  is  beta- 
naphthol  and  salol,  along  with  arsenic 
when  that  can  be  borne.  William  Hunter 
(Brit.  Med.  Jour.,  Apr.,  '94). 

[I  would  take  exception  to  Hunter's 
statement  that  salol  is  an  intestinal  an- 
tiseptic. "An  intestinal  antiseptic,"  ac- 
cording to  Bouchard, — and  there  is  no 
better  authority, — "must  be  more  or  less 
insoluble  and  e.xert  no  toxic  action  on 
the  organism.  This  definition  excludes 
salol,  which  no  sooner  comes  in  contact 
with  the  alkaline  secretions  of  the  intes- 
tine than  it  splits  into  carbolic  and 
salicylic  acids,  both  of  which  are  rapidly 
absorbed." 

The   best   intestinal   antiseptic   is   un- 
doubtedly thymol:    a  fact  which  seems 
to   be   more   fully   appreciated   in   Italy 
than  elsewhere.     In  accordance  witli  the 
view  that  pernicious  anaemia  is  due  to 
the  absorption  from  the  intestine  of  sub- 
stances foreign  to  the  healthy  body,  and 
destructive    to    the    red    corpuscles,    its 
treatment    by    intestinal    antiseptics    is 
certainly  most  rational.     F.  P.  Henry, 
Assoc.  Ed.,  Annual,  '95.] 
"When  the  disease  is  due  to  the  an- 
chylostonia   diiodenale,   thymol,   2   to   3 
drachms  daily,  is  a  very  effective  vermi- 
cide, according  to  Bozzolo. 

Senim-therapy  seems  to  merit  further 
trial. 

Antistreptococcic  serum  used  with 
gratifying  results  in  two  cases  of  anoe- 
mia:  one  pernicious,  the  other  simple. 
In  the  former,  examination  of  the  blood 
showed  4000  white  and  less  than  1,000,- 
000  red  corpuscles  to  the  cubic  centi 
metre,  and  30  per  cent,  of  htemoglobin 
Eight  injections  of  8  cubic  centimetres 
each  were  given  at  intervals  of  two  or 
three  daj's.  After  the  third,  improve 
ment    began    and    progressed     steadily. 


Three  days  after  the  last  injection  the 
blood  contained  5000  white  and  4,960,000 
red  corpuscles,  and  90  per  cent,  of  haemo- 
globin. W.  H.  de  Witt  (Cin.  Lancet- 
Clinic,  Ixxxiv,  p.  61,  1900). 

Case  of  a  man,  37  years  of  age,  whose 
symptoms,  on  coming  under  observation, 
were:  (1)  weakness  and  extreme  anae- 
mia— the  red  corpuscles  were  27  per  cent, 
and  hsemoglobin  35  per  cent.,  with  poiki- 
loeytosis;  (2)  a  lemon  color  of  the  skin 
with  urobilinuria ;  (3)  a  sore  tongue, 
dental  neci-osis,  suppuration  of  the  gums, 
and  gastric  pains;  (4)  tingling  and 
numbness  of  the  fingers  and  irregular 
pyrexia. 

The  treatment  consisted  of  oral  and 
gastric  antisepsis.  During  July  three  in- 
jections of  antistreptococcic  serum  were 
given.  After  the  first  the  red  corpuscles 
rose  to  30  per  cent.;  after  the  second  to 
52  per  cent.;  and  in  three  weeks  the  red 
corpuscles  rose  to  65  per  cent,  and  the 
hsemoglobin  to  72  per  cent.  In  Septem- 
ber arsenic  was  added  to  the  other  treat- 
ment, and  by  December  the  red  corpus- 
cles had  risen  to  94  per  cent,  and  the 
hsemoglobin  to  100  per  cent.  William 
Hunter   (Lancet,  Mar.  30,  1901). 

Feederick  p.  Heney, 

Philadelphia. 

AN.a:STHESIA.  See  individual  anaes- 
thetics. 

ANALG-EN.  —  Analgen  is  a  derivative 
of  quinoline  and  occurs  as  a  white  crys- 
talline powder  readily  soluble  in  hot  alco- 
hol, slightly  so  in  cold  alcohol,  but  in- 
soluble in  water.    It  is  tasteless. 

Dose. — The  dose  is  from  4  to  10  grains, 
repeated  every  three  hours  if  necessary. 
Maximum  single  dose  15  V=  grains  and 
the    maximum    daily    dose     1     drachm. 
Schreiber     (Amer.     Medico-Surg.     Bull., 
Jan.  25,  '95). 
Although   of  no  pathological  signifi- 
cance, the  fact  that  analgen  causes  a  red 
discoloration    of    the    urine    sometimes 
frightens  the  patient,  and  he  should  be 
informed  of  this  phenomenon. 


ANESIN. 


295 


Physiological  Action. — Analgen  seems 
to  act  upon  the  sensitive  centres,  lower- 
ing their  excitability.  The  separation 
products  of  the  drug  are  frequently  elim- 
inated by  the  urine,  which  is  of  a  red 
color,  rendered  more  marked  by  the  ad- 
dition of  acetic  acid, — 1  to  10  (Dujardin- 
Beaumetz  and  Dubief).  Bicarbonate  of 
soda,  given  internally,  is  said  to  prevent 
this  discoloration. 

Therapeutics. — Analgen  is  mainly  used 
in  the  treatment  of  conditions  in  which 
pain  is  a  prominent  feature. 

jSTeukalgia. — In  this  disorder  it  often 
proves  very  efficient. 

Antineuralgic  action  tested  in  22  oases. 
In  10  of  simple  neuralgia,  8  recoveries, 
the  2  failures  being  in  hysterical  sub- 
jects. In  3  cas.es  of  migrr.ine,  1  cured. 
Succeeded  in  3  cases  of  rheumatic  pains. 
Failed  in  zona  and  tabetic  pains.  Un- 
toward symptoms:  an  intense  headache 
in  1  patient  and  buzzing  in  the  ears. 
Spiegelberg  (Munchener  med.  Woch., 
Apr.  4,  '93). 

Used  in  about  two  hundred  cases,  the 
majority  neuralgia.     The  full  dose  of  15 
grains  necessary  to  produce  relief.     Foy 
(Med.  Press  and  Circular,  June  13,  '94). 
Febeile  Conditions. — In  the  various 
disorders  presenting  fever  as  a  promi- 
nent symptom,  whether  due  to  malaria, 
infectious   processes,    or    to    the    undue 
presence   in   the   blood   of   products    of 
elimination,   it  has  been   credited  with 
considerable  merit. 

Analgen  is  valuable  as  an  antipyretic 
and  germicide.  One  and  one-fourth  to 
1  'A  drachms  daily  cause  fall  of  tem- 
perature of  from  3  1°  to  5°  F.,  within 
half  an  hour  after  the  first  dose  of  15 
to  30  grains,  continuing  for  three  days, 
often  accompanied  by  profuse  perspira- 
tion. Phthisical  patients  experience  a 
peculiar  feeling  of  well-being  from  its 
use.  In  doses  of  ^/,,  to  1  drachm  it  acts 
remarkably  on  muscular  or  acute  articu- 
lar rheumatism.  It  does  not,  however, 
prevent  relapses  or  complications.  Maas 
(Zeit.  f.  klin.  Med.,  B.  28,  H.  1,  2,  '95). 


Used  exclusively  in  59  cases  of  chil- 
dren, ages  of  the  patients  ranging  from 
20  days  to  13  years,  33  being  various 
manifestations  of  malarial  poisoning. 
The  dosage  varies  from  3 '/,  grains  to 
45  grains  in  twenty-four  hours.  No  un- 
favorable action  upon  the  respiration  or 
circulation.  Urine  deep  yellow  or  red, 
albumin  or  sugar  never  present.  Action 
prompt  and  efficient,  reducing  tempera- 
ture and  shortening  the  period  of  the 
disease.  Moncorvo  (Bull,  de  I'Acad.  de 
M6d.  de  Paris,  Nov.  10,  '96). 

ANALGESINE.    See  Anxipteine. 

ANCHYLOSTOMTJM.  See  Paeasites, 
Intestinal. 

ANESIN. — Anesin  is  a  trichlorpseudo- 
butyl-alcohol,  or  acetone  chloroform,  a 
1-per-cent.  solution  of  which  is  said  to 
possess  the  anesthetic  power  of  a  2  ^/o 
solution  of  cocaine  hydrochlorate.  It  is 
also  reported  by  Vamossy  as  capable  of 
standing  unimpaired  as  a  solution  for  a 
long  time.  It  is  said  to  be  sterile  and 
non-poisonous  and  to  produce  no  local 
irritation. 

Dose. — The  2-per-cent.  solution  is  used 
as  a  local  aniesthetic  in  the  same  manner 
as  cocaine.  It  may  also  be  injected  sub- 
cutaneously. 

Physiological  Action. — "When  applied 
to  the  tongue,  anesin  first  gives  rise  to 
a  sensation  suggesting  the  presence  on 
the  organ  of  a  foreign  body.  This  soon 
disappears,  and  is  replaced  by  local  an- 
ajsthesia.  It  acts  in  the  same  manner 
when  injected  subcutaneously. 

Therapeutics. — Anesin  has  so  far  been 
tried  as  an  anassthetic  in  diseases  of  the 
eye  and  throat  and  in  minor  surgery. 
It  is  also  credited  with  hypnotic  proper- 
ties by  Kossa. 

Ophthalmology.  —  Its  main  use  has 
been  as  a  local  anesthetic  in  ophthal- 
mology.     Grosz    has    recommended    it. 


396 


ANEURISM. 


owing  to  the  fact  that  it  does  not  cause 
mydriasis.  In  important  operations, 
however,  lie  prefers  cocaine.  Anesin 
only  anaesthetizes  the  spot  to  which  it 
is  applied,  its  power  of  diffusion  being 
small.  It  does  not  produce  anesthesia 
of  the  iris. 

Laeyngologt. — Anesin  was  found  by 
Israi  to  cause  prompt  local  anaesthesia  of 
the  nasal  mucous  membrane  of  the  phar- 
ynx and  larynx  without  giving  rise  to 
untoward  symptoms.  It  does  not,  how- 
ever, produce,  even  in  strong  solutions, 
the  profound  anaesthesia  resulting  from 
the  use  of  equally  strong  solutions  of 
cocaine. 

Minor  Surgery.  —  Antal  has  tried 
anesin  in  dental  operations  and  found 
it  very  useful.  Hiild  found  it  equally 
valuable  in  all  kinds  of  operations,  and 
emphasizes  the  fact  that  its  harmless- 
ness  should  insure  its  preference  over 
cocaine  in  all  minor  operative  proced- 
ures. 

Anesin  in  a  2-per-eent.  solution  gives 

rise    to    no    local    irritation    or    general 

poisoning.     It  is  an  effective  anaesthetic. 

V.  Vamossy  (Deutsche  med.  Woeh.,  Sept. 

2,  '97). 

ANEURISM.  — From  Greek,  dvd, 
through,  and  evpvi'Cd,  I  widen. 

Definition. — A  tumor  containing  blood 
or  formed  by  a  localized  dilatation  of 
a  blood-vessel,  communicating  with  the 
interior  of  that  vessel.  It  may  involve 
an  artery  or  a  vein,  or  both  conjointly. 

Arterial  Varieties, — As  to  cause,  arte- 
rial aneurisms  may  be  divided  into  two 
classes: — 

Idiopathic,  or  spontaneous,  in  which 
the  aneurism  is  due  to  disease  of  the 
arterial  walls. 

Traumatic,  in  which  it  is  due  to  an 
injury  of  a  perfectly  healthy  vessel. 

Idiopathic  Aneurisms.  —  These  are 
subdivided  into  three  varieties: — 


1.  Tubulated,  or  fusiform,  in  which 
the  three  coats  of  the  artery  are  dilated 
simultaneously.  The  dilatation  affecting 
the  circumference  as  well  as  the  length 
of  the  vessel,  it  presents  the  appearance 
of  a  circular  enlargement  rather  than 
that  of  a  tumor.  It  is  usually  observed 
in  the  cranial,  thoracic,  and  abdominal 
cavities,  and  is  generally  smaller  than 
the  other  varieties  of  aneurism. 

2.  Sacculated,  in  which  the  aneurism 
projects  from  the  side  of  the  artery  or 
from  that  of  a  tubular  aneurism.  These 
are  usually  divided  into  true  aneurisms, 
in  which  all  the  coats  of  the  artery  are 
dilated,  and  false  aneurisms,  in  which 
but  two  coats  of  the  artery  remain:  the 
internal  and  the  outer.  The  former  do 
not  attain  great  size,  while  the  latter  may 
assume  enormous  proportions. 

[The    distinction   made    between    true 
aneurisms,   -where   all   the    coats   of  the 
artery  are  dilated,  and  false  aneurisms 
(traumatic  aneurisms),  where  the  walls 
do  not  consist  of  all  three  arterial  coats, 
is  artificial  and   incorrect,  according  to 
Cohnheim.    J.  McFadden  Gaston.] 
A  false,  sacculated  aneurism  may  be 
circumscribed,  the  sac  in  that  case  re- 
maining whole,  or  diffuse,  the  sac  having 
ruptured,  allowing  the  blood  to  become 
diffused    into    the    surrounding    tissues, 
where  it  may  become  imprisoned  by  an 
artificial  cavity  formed  by  the  neighbor- 
ing cellular  tissue. 

3.  Dissecting,  in  which  an  early  rupt- 
ure of  an  atheromatous  abscess  in  the 
arterial  wall  has  enabled  the  blood  to 
dissect  its  way  between  the  internal  and 
external  coats  until,  sooner  or  later,  it 
makes  an  issue  for  itself  into  the  inte- 
rior of  the  vessel  or  exteriorly.  In  the 
former  ease  it  assumes  the  shape  of  a 
sessile  growth.  This  form  occurs  espe- 
cially in  the  aorta,  where  it  may  suggest 
the  presence  of  a  double  aorta,  and  in 
the  smaller  cerebral  arteries. 


ANEURISM.     SYMPTOMS. 


297 


Symptoms.  —  The  patients  are  some- 
times made  conscious  of  the  formation 
of  an  aneurism  by  feeling  something 
give  way,  or  a  sndden,  sharp  pain,  or,  in 
orbital  aneurism,  hearing  a  sound  like 
a  percussion-cap. 

The  subsequent  symptoms  vary  ac- 
cording to  the  stage  of  development  at 
the  time  the  case  is  examined. 

During  the  first  stage — i.e.,  the  period 
intervening  between  the  onset  and  the 
time  when  the  sac  has  become  firm — 
pulsation  of  the  tumor  is  clearly  felt  at 
each  beat  of  the  heart.  If  both  hands 
are  placed  over  it,  the  expansion  of  the 
growth  will  tend  to  separate  them. 
When  it  is  possible  to  apply  pressure  on 
the  artery  above  the  tumor,  its  size  is 
diminished,  while,  if  applied  below,  the 
contrary  is  the  case.  The  reason  for  this 
is  obvious:  when  the  pressure  is  applied 
above  the  aneurism  the  flow  of  blood 
into  the  cavity  is  interfered  with,  while 
the  blood-pressure  is  increased  within 
the  cavity  when  pressure  is  exerted  be- 
low. This  method  of  examination,  how- 
ever, is  not  altogether  safe. 

The  pulsations  of  the  heart  above  the 
seat  of  the  aneurism  are  weaker  and 
slightly  retarded.  Sphygmographic  trac- 
ings are  also  modified  from  the  normal 
type. 

Auscultation  will  reveal  a  blowing  or 
rasping  bruit  not  only  in  the  aneurism, 
but  also  in  its  artery,  extending  some 
distance  beyond  the  sac.  This  bruit  is 
not  present  in  every  case.  It  is  also 
heard  in  malignant  vascular  tumors,  but 
it  is  strictly  localized  to  the  growth, 
being  never  transmitted  along  the  artery. 

The  second  stage  begins  when  the 
aneurismal  sac  has  become  firm  and 
resisting,  on  account  of  the  deposit  of 
laminated  fibrin  within  it.  In  some 
cases  no  fibrinous  deposit  is  formed,  so 


that  no   second   stage   can   properly   be 
taken  as  a  guide. 

The  pulsation  becomes  more  indis- 
tinct, or  even  altogether  lost,  on  account 
of  the  thickening  of  the  aneurismal  wall 
and  the  deposit  of  fibrin.  If  the  layer 
of  fibrin  is  not  of  the  same  thickness 
everywhere,  the  pulsation  may  be  more 
distinct  at  some  points  over  the  sac. 

Pressure  over  the  sac  causes  cessation 
of  the  pulsation,  but  the  aneurismal  tu- 
mor will  not  vanish,  on  account  of  the 
fibrin  deposited  within  it. 

A  bruit  will  generally  be  heard  over 
the  sac  and  along  the  artery,  but,  like 
the  pulsation,  will  be  detected  with  vary- 
ing distinctness  according  to  the  portion 
of  the  sac  examined. 

Pain  may  he  an  early  symptom  of 
aneurism;  it  is  more  commonly  found  in 
the  second  stage,  when  it  may  be  sharp 
and  lancinating  or  resemble  the  aching 
or  boring  of  v.lceration.  It  is  due  to  the 
pressure  produced  by  the  tumor  on  the 
nerves,  and  is  consequently  intense  in 
popliteal  aneurism  along  the  course  of 
the  popliteal  nerve,  which  is,  at  times, 
flattened  out  upon  the  tumor. 

Case  in  which  there  was  no  pain:  a 
very  constant  symptom  in  thoracic 
aneurism.  Nevertheless,  the  face  flushed 
Avhen  the  head  was  lowered,  there  was 
tracheal  tugging;  no  fremitus  could  be 
felt  over  the  left  side  of  the  chest;  there 
was  no  pulsation  in  the  left  carotid,  and 
the  radial  pulse  on  the  left  side  was 
small.  The  loss  of  fremitus  is  one  of 
the  earliest  signs  of  aneurismal  pressure. 
Glynn   (Brit.  Med.  Jour.,  Feb.  6,  '97). 

If  located  in  one  of  the  extremities, 
oedema  of  the  limb  constantly  occurs 
after  the  aneurism  has  reached  a  cer- 
tain size.  It  is  due  to  pressure  upon  the 
veins,  and  may  not  only  be  painful,  but 
also  terminate  in  ulceration  and  slough- 
ing. 

Gangrene  is  a  late  symptom  and  may 


298 


ANEURISM.    DIFFERENTIAL  DIAGNOSIS. 


suddenly  be  caused  by  an  embolus.  Usu- 
ally it  is  due  to  excessive  oedema. 

An  aneurism  may  press  upon  various 
organs.  If  bone  is  compressed  the  pain 
is  boring  and  gnawing,  and  results  in  the 
absorption  of  the  osseous  tissue. 

Glands  may,  through  this  cause,  cease 
their  functions. 

Compression  of  the  trachea  causes  dif- 
ficulty in  respiration;  of  the  oesophagus, 
trouble  in  swallowing.     If  the  thoracic 


Aneurism  of  the  ascending,  transverse, 
and  upper  portions  of  the  descending 
aorta,  a,  Point  of  rupture.  (A.  A. 
Smith.) 

duct  is  interfered  with,  nutrition  is  im- 
paired. 

A  peculiar  brassy  cough  is  produced 
by  compression  of  the  recurrent  laryn- 
geal nerve.  Hiccough  is  frequently  a 
result  of  pressure  on  the  phrenic  nerve, 
while  marked  capillary  congestion  may 
be  caused  by  pressure  on  the  sympathetic 
nerve. 

Intracranial  aneurism  may  give  rise 
to  hemiplegia,  facial  paralysis,  deafness, 


ptosis,  blindness,  or  strabismus,  caused 
by  pressure  on  various  nerves. 

Case  of  aneurism  of  the  middle  cere- 
bral artery  in  a  male  65  years  of  age. 
The  attack  had  begun  with  a  very 
marked  vertigo.  Soon  after  he  was  dis- 
covered he  became  speechless.  Breathing 
was  very  slow  and  irregular,  and  face 
was  flushed.  Both  pupils  were  con- 
tracted, the  right  one  slightly  more  than 
the  left.  Paralysis  of  the  left  side,  which 
gradually  increased  and  extended  to  the 
left  leg.  Death  on  the  second  day.  On 
autopsy,  very  decided  hardness  of  the 
middle  cerebral  artery  found,  and  an 
aneurismal  sac  dissected  out,  which 
measured  one  centimetre  in  length  and 
one-half  centimetre  in  diameter,  and 
Avas  ovoid  in  shape.  On  first  examina- 
tion it  had  closely  resembled  an  ordinary 
cerebral  haemorrhage.  T.  M.  Prudden 
(Med.  Record,  Nov.   1.3,  '97). 

Differential  Diagnosis. 

Abscess.  —  Although  in  abscess  the 
pulsation  is  distinct,  it  is  not  expansile. 
If  the  artery  above  the  abscess  be  com- 
pressed, pulsation  will  be  felt  as  soon 
as  pressure  is  removed,  and  not,  as  in 
aneurism,  only  after  the  aneurismal  sac 
has  been  filled. 

A  case  of  aneurism  of  tlie  femoral 
artery  in  a  child  which  simulated,  to  a 
certain  extent,  an  abscess  resulting  from 
coxalgia.  Differential  diagnosis  was 
made  on  the  presence  of  expansile  pulsa- 
tion, a  AA-ell-marked  thrill  and  bruit,  and 
the  presence  of  heart  disease.  Sac  was 
opened  and  cleared  of  clot.  Johnson 
(Quart.  Med.  Jour.,  Oct.,  '98). 

Pulsating  Tumors.  — •  Vascular  sar- 
coma, pulsating  encephaloid,  hsematocele, 
and  erectile  tumors  in  general  are,  as 
a  rule,  not  expansile.  This  differential 
sign  is  especially  valuable  when  a  tumor 
overlies  an  artery. 

Eheumatism. — The  pain  of  aneurism 
sometimes  suggests  rheumatism  at  its 
onset,  especially  when  the  aneurism  is 
popliteal. 


ANEURISM.     DIFFERENTIAL  DIAGNOSIS. 


299 


Neuralgia.  —  Pain  is  strictly  local- 
ized, and  none  of  the  symptoms  denoting 
an  expansile  growth  are  present. 

Aeteeial  Pulsation.  —  Localized, 


Thoracic  aneurism.  Examination  with  fluoro- 
scope:  Tire  curved  line  in  the  upper  part  of 
patient's  left  chest  and  the  curved  line  on 
his  right  chest  indicate  the  outline  of  the 
aneurism  as  seen  in  the  fluoroscope.  The 
lower  curved  line  on  the  left  chest  marks 
the  outline  of  the  heart;  the  lowest  curve 
on  the  right  front,  part  of  the  outline  of 
the  diaphragm;  the  dotted  line,  the  cardiac 
area  as  determined  by  percussion.  This  case 
shows  how  a  large  aneurism  may  exist  in 
the  chest  without  giving  rise  to  niai'ked 
physical  signs.  (F.  H.  WiUiams,  Amer. 
Jour.  Med.  Sci.,  Dec,  '97.) 

but  not  persistent,  pulsations  of  arteries 
may  simulate  aneurisms,  and  have  been 
described  by  Paget  and  West  under  the 
nam-es  of  mimic  or  phantom  aneurisms. 
Hjsmothoeax  and  Empyema. — These 
complications  of  pleuro-pulmonary  dis- 
eases may  be  simulated  when  an  aortic 
aneurism  has  ruptured. 

Value  of  x-rays  in  the  diagnosis  of 
thoracic  aneurism  in  which  the  outlines 
of  the  aortic  swelling  are  clearly  shown. 
In  one  case  (possibly  of  tuberculous 
adenitis),  in  which  the  symptoms  sug- 
gested an  aneurism,  the  sciagraph  showed 
no  enlargement  of  the  aorta.  The  arrest 
of  the  x-rays  by  an  aneurismal  tumor  is 
due  to  the  blood  and  probably  to  the 
iron  contained  in  it.  Tuberculous  de- 
posits are  thought  to  be  impervious  to 


the  rays,  but  this  is  still  a  matter  of 
some  uncertainty.  In  the  cases  in  which 
aneurism  existed,  the  diagnosis  had  al- 
ready been  made,  but  the  picture  made 
by  Roentgen  rays  confirmed  this  diag- 
nosis. William  Pepper  (Med.  Record, 
Nov.  28,  '90). 

Aneurisms  of  the  thoracic  aorta  can 
sometimes  be  detected  eai'lier  by  x-ray 
examination  than  in  any  other  way. 
In  obscure  cases,  where  an  aneurism  of 
certain  portions  of  the  aorta  is  suspected, 
but  does  not  exist,  it  may  be  excluded 
by  an  x-ray  examination.  (See  wood- 
cuts.) Francis  H.  Williams  (Amer.  Jour. 
Med.  Sciences,  Dec,  '97). 

As  aneurisms  of  the  valves  are  chiefly 
dependent  on  endocarditis  and  atheroma, 
the  symptoms  are  those  of  these  diseases, 
and  they   have   no   separate   symptoma- 


These  two  figures  show  a  smaller  aneurism  of 
the  aorta.  The  arrow  on  the  dorsal  side 
points  to  where  the  pulsation  was  best  seen. 
(F.  H.  Williams,  Amer.  Jour.  Med.  Sci., 
Dec,  '97.) 


300 


ANEURISM.     ETIOLOGY. 


tology;  yet  the  auscultatory  phenomena 
may  have  diagnostic  significance.  Aneu- 
rism of  the  mitral  may  produce  a 
rudimentary  murmur  immediately  fol- 
lowing the  systole.  Frequently  in  per- 
forated aneurisms  the  sounds  are  most 
peculiar:  humming,  blowing,  groaning, 
hissing,  singing,  whistling,  scratching, 
piping,  or  musical.  A  musical  murmur, 
especially  in  the  aorta,  which  was  not 
present  in  an  apparently-healthy  indi- 
vidual the  day  previously,  may  be  looked 
upon  as  dependent  on  valvular  aneurism. 
Musical  murmurs  due  to  aneurisms  may 
disappear  for  days  and  then  return. 
They  may  vary  in  time,  place,  and 
quality.  They  can  only  be  properly  in- 
terpreted when  taken  in  connection  with 
other  physical  signs  yielded  by  the  heart. 
Drasehe  (Wiener  klin.  Woeh.,  Nov.  10, 
'98). 

Diagnosis  between  aneurism  and  me- 
diastinal tumors  based  upon  150  cases 
of  aneurism,  200  cases  of  stenosis  of  the 
ffisophagus,  and  a  large  number  of  other 
eases  of  mediastinal  tumor.  The  most 
important  signs  of  mediastinal  disease 
are  stenosis  and  pressure-paralyses  of 
the  recurring  nerve.  Tracheal  stenosis 
is  the  most  important  of  the  various 
forms  of  stenosis,  and  if  it  is  present 
the  probability  of  the  presence  of  aneu- 
rism is  very  great.  Permanent  signs  of 
stenosis  of  the  oesophagus  constitute 
almost  secure  evidence  of  mediastinal 
disease,  and  exclude  aortic  aneurism. 
Hampeln  (Zeits.  f.  klin.  Med.,  B.  xlii,  H. 
3  and  4,  1901). 

Five  eases  in  which  the  Roentgen  rays 
proved  of  value  in  the  diagnosis  of  tho- 
racic aneurism.  A  transverse  position 
of  the  heart  is  an  important  sign. 
AValsham  (Edinburgh  Med.  Jour.,  Apr., 
1901). 

Etiology.  —  Age  is  an  important  fac- 
tor, aneurisms  being  observed  especially 
in  adults  in  their  prime:  i.e.,  between 
thirty  and  forty  years  of  age.  This  is 
due  to  the  fact  that  men  are  still  en- 
gaged in  vigorous  occupations  at  that 
age,  neither  the  heart  nor  the  muscles 
having  lost  their  strength,  while  it  is 
then  that  arteries  begin  to  show  symp- 


toms of  degeneration.  In  very  young 
people  aneurisms  are  exceedingly  un- 
common. 

As  to  sex,  females,  owing  to  their  less 
active  life,  are  but  little  affected  with 
aneurism,  the  proportion  being  one  to 
seven,  as  compared  to  males. 

Spontaneous  aneurism  is  usually  due 
to  degeneration  of  the  artery-wall  caused 
by  atheroma  or  adipose  infiltration.  As 
a  result,  the  artery  is  imable  to  con- 
tract during  the  cardiac  diastole,  and  its 
diminished  resistance  to  the  pressure  of 
the  blood  caused  the  vascular  walls  to 
gradually  dilate.  As  atheroma  presents 
itself  chiefly  during  middle  life,  while 
physical  use  of  the  system  is  still  violent, 
this  class  of  aneurism  is  most  frequently 
met  with  in  people  between  thirty  and 
forty  years  of  age.  Inflammatory  changes 
are  also  considered  as  a  proliflc  cause. 

Aneurism  i3  solely  a  consequence  of 
alterations  of  the  arterial  walls,  particu- 
larly arteritis.  Alcoholism  accounts  for 
great  frequency  of  this  affection  in  cer- 
tain countries.  Localization  in  arterial 
coats  depends  upon  the  more  or  less  ad- 
vanced degree  of  sclerosis  or  atheroma. 
Duplaix  (Des  Anevrysmes  et  de  leur 
Traitement,  "95). 

The  old  theory  that  degeneration  of 
the  wall  of  the  artery  always  precedes 
aneurism  of  any  vessel  is  the  true  one. 
Loss  of  vascular  tone  can  scarcely  be 
accepted  as  a  sufficient  cause.  A.  Mc- 
Phedran  (Can.  Pract.,  Aug.,  '98). 

Aneurism  of  the  abdominal  aorta 
noted  in  a  boy,  9  years  of  age,  who  had 
been  repeatedly  the  subject  of  rheuma- 
tism. There  was  also  atheroma  of  the 
aorta,  and  in  two  places  there  were  be- 
ginning aneurisms  of  the  arch.  The 
aneurism  of  the  abdominal  aorta  was  as 
large  as  a  golf-ball.  It  was  at  the  divi- 
sion of  the  common  iliac  arteries.  R.  K. 
Aitken  (Brit.  Med.  Jour.,  June  25,  '98). 
Syphilis  is  a  common  etiological  factor. 

Importance  of  syphilitic  arteriosclero- 
sis in  the  production  of  aneurisms  in- 
sisted upon.    Of  twenty-eight  cases  syph- 


ANEURISM.    ETIOLOGY. 


301 


ilis  found  to  e.vist  in  twelve.  Heiberg 
(La  Semaine  Medicale,  July  27,  '92). 

Of  nineteen  patients  47  per  cent,  had 
had  syphilis,  all  under  fifty  years  of  age. 
This  illustrates  the  relation  of  precocious 
arteriosclerosis  and  syphilis.  Fraenkel 
(Med.  Record,  N.  Y.,  Nov.  17,  '94). 

Among  European  residents  of  Japan 
aneurisms  of  the  abdominal  and  thoracic 
aorta  are  very  frequent;  syphilis  is  very 
common.  Eldridge  (N.  Y.  Med.  Jour., 
Feb.  10,  '94). 

Syphilis  found  to  be  a  possible  cause 
in  one  hundred  and  si.xty-six  cases  out 
of  two  hundred  and  forty.  In  twenty- 
eight  of  the  one  hundred  and  sixty-six 
cases  syphilitic  lesions  were  present.  The 
greatest  frequency  of  aneurisms  occurs 
between  five  and  ten  years  after  syphi- 
litic infection. 

In  the  great  majority  of  cases  aneu- 
risms due  to  syphilis  cannot  be  distin- 
guished from  aneurisms  due  to  other 
causes,  nor  are  any  special  pathological 
lesions  present.  Differentiation  by  treat- 
ment is  not  reliable.  Etienne  (Ann.  de 
Dermatologie,  vol.  viii,  p.  1,  '97). 

The  term  "dissecting  aneurism"  has 
been  applied  to  a  form  in  which,  the 
inner  walls  of  the  aorta  or  one  of  the 
large  arteries  having  ruptured,  the  outer 
coats  remain  intact,  the  blood  dissect- 
ing a  passage  between  the  layers  of  the 
middle  coat.  There  are  altogether  about 
two  hundred  cases  of  this  condition  re- 
corded, and  in  by  far  the  larger  number 
of  these  death  evidently  occurred  either 
immediately  or  within  a  few  hours,  most 
frequently  by  the  blood  forcing  its  way 
into  the  ascending  aorta  and  thence 
into  the  pericardial  sac.  Only  in  a  small 
percentage  of  the  cases  was  compensa- 
tion established  and  the  dissecting  chan- 
nel repaired  either  by  the  development 
of  secondary  openings  into  the  vessel  or 
by  the  organization  of  the  blood,  which, 
after  escaping  between  the  walls,  became 
clotted.  There  are  singularly  few  cases 
on  record  of  this  last  mode  of  repair;  it 
is   more    common    to    find    that,    where 


death  is  not  the  direct  result  of  the  con- 
dition, the  dissecting  channel  gains  an 
endothelium,  a  channel  being  formed, 
opening  above  and  below  into  the  aorta 
or  one  of  the  larger  arteries,  and  resem- 
bling the  primitive  vessel  so  closely  that 
it  is  not  to  be  wondered  at  that  some 
of  the  earlier  cases  of  the  condition  were 
described  as  congenital  abnormalities. 
(Adami.) 

Dissecting  aneurisms  may  be  due,  in 
the  old,  to  atheromatous  change;  in  the 
3'oung  to  congenital  malformation  of  the 
central  organs  of  the  circulation;  some- 
times, also,  to  traumatism.  Hypertrophy 
of  the  heart,  especially  in  its  left  half,  is 
often  present.  Traces  of  peri-  or  endo- 
carditis are  often  to  be  noted.  The  rent 
in  the  inner  coat  sometimes  precedes, 
sometimes  follows,  the  distension.  A 
number  of  rents  may  occur  in  the  same 
subject. 

Double  aorta  and  dissecting  aneurism. 
The  upper  and  posterior  wall  of  the 
aorta  exhibited  an  opening  one-fourth 
of  an  inch  in  diameter  and  nearly  round. 
The  aneurism  had  its  origin  in  a  rupture, 
not  of  the  main  artery,  but  in  a  channel 
to  the  left  of  it.  It  had  stripped  oflf 
the  pleura  on  the  left  side  and  had 
broken  through  this,  causing  the  fatal 
haemorrhage  into  that  cavity.  A  careful 
examination  showed  that  there  was  a 
duplication  of  the  aorta-  from  the  left 
subclavian  down^  the  two  portions  be- 
ing separated  by  a  complete  septum. 
The  right  was  the  larger  and  was  in  line 
with  the  descending  limb  of  the  arch. 
The  left  branch  did  not  exhibit  arterio- 
sclerosis. 

This  condition  is  very  rare.  Krause 
cited  five  examples  of  double  aorta.  In 
view  of  the  fact  that  in  the  development 
of  the  human  embryo  the  right  and  left 
systems  of  arterial  arches  fuse  together 
at  a  very  earlier  period,  it  is  astonishing 
that  the  man  should  have  lived  to  a  good 
age  in  health  and  comfort.  Williams 
(Med.  Record,  Aug.  1,  '96). 

As  to  the  etiology  of  dissecting  aneu- 


302 


ANEURISM.    PATHOLOGY. 


risms,  it  is  probable  that  neither  trauma 
nor  disease  plays  any  part  in  the  ma- 
jority of  instances.  It  is  more  than 
likely  that  the  initial  tear  in  the  inner 
coats  is  due  to  the  distension  of  the 
lumen  of  the  vessels  in  consequence  of 
the  increased  action  of  an  hypertrophied 
left  ventricle.  That  the  intima  and 
media,  and  not  the  adventitia,  should  be 
torn  is  explained  by  the  fact  that  the 
adventitious  coat  is  more  elastic  than 
the  other  two.  Floekmann  (Miinehener 
med.  Woch.,  July  5,  '98). 

Aneurisms  are  sometimes  of  parasitic 
origin  and  caused  by  embolism  or  by  ero- 
sion of  the  arterial  wall  from  without, 
— ordinarily  due  to  tuberculous  foci  as 
found  in  cavities  in  the  lungs.  Sponta- 
neous aneurisms  are  common  in  patients 
with  increased  intravascular  pressure,  as 
in  Bright's  disease  or  valvular  disease  of 
the  heart. 

Every  horse  has  an  aneurism,  from  the 
size  of  a  pigeon's  egg  to  that  of  a  man's 
head,  in  the  mesenteric  artery  of  the 
caecum,  caused  by  the  sclerostomum 
armatum.  Czokor  (Inter,  klin.  Rund., 
Kov.  26,  '93). 

Exciting  Causes. — Weakness  and 
thinness  of  the  internal  and  medial  coats 
of  the  arteries  predispose  to  aneurisms, 
especially  in  localities  like  the  popliteal 
space,  subject  to  frequent  movements. 
Small,  incomplete  tears  occur  in  the  wall 
of  the  vessel,  and  these  gradually  increase. 
Violence  may  then  produce  a  rupture  of 
one  or  two  of  the  coats  of  an  artery  and 
act  as  an  exciting  cause. 

An  artery  may  be  torn  or  unduly 
stretched  by  a  fracture  or  dislocation,  or 
by  attempts  made  to  reduce  the  latter. 

Case  of  traumatic  aneurism  of  the  axil- 
lary artery  due  to  attempts  at  reduction 
of  a  dislocation  of  the  shoulder.  Death 
soon  after  the  operation.  A  small  open- 
ing found  in  the  axillary  artery  only 
large  enough  to  admit  the  end  of  a 
probe;  the  sac  was  enormous  and  dur- 
ing  life   had   not  pulsated.     The  veins, 


which  had  been  also  injured,  opened  into 
the  aneurism. 

Case  of  traumatic  aneurism  due  to  at- 
tempted freeing  of  the  shoulder-joint,  in 
a  case  of  ankylosis  following  gonorrhoeal 
arthritis.  Sonnenburg  (Berliner  klin. 
Woch.,  p.  681,  July  27,  '96). 

Any  violent  or  sudden  exertion  may 
also  act  as  an  exciting  cause  either  by 
unduly  stretching  the  artery,  by  forcing 
blood  under  a  high  pressure  through  it, 
or  by  causing  the  heart  to  act  irregularly 
and  forcibly. 

Case  of  child  which,  when  first  seen, 
when  nine  days  old,  had  in  the  left  axilla 
a  tumor,  soft  and  compressible,  dilating 
synchronously  with  the  heart,  and  over 
which  a  bruit  could  be  heard,  but  there 
was  no  aneurismal  thrill  apparent.    This 
tumor  had  not  been  noticed  at  birth  by 
the  midwife,  but  some  days  later  a  small, 
soft  swelling  was  observed  which  gradu- 
ally filled  the  entire  axilla.     The  tumor 
was  flattened  and  soft,  covering  the  an- 
terior aspect  of  the  shoulder  and  a  small 
part  of  the  upper  arm;    beneath,  it  ex- 
tended  beyond   the   posterior  border   of 
the  axillary  space.     The  child  had  been 
roughly  handled  a  day  or  two  after  birth, 
during   the   performance   of   some   occult 
ceremonial  rites,  part  of  which  rites  con- 
sisted in  handling  the  child  dangling  by 
one  arm  from  one  person  to  another  over 
the  banisters.     When  shown,  child  was 
in  excellent  health,  after  having  passed, 
however,     through     a     period     of    some 
months'  suffering.    W.  C.  Mardorf  (Med. 
Rev.,  May   14,   '98). 
Eiders  are  frequently  the  subjects  of 
popliteal  aneurisms.    This  is  due  to  ob- 
struction of  the  arteries  caused  by  the 
bending  of  the  legs  and  the  contraction 
of   the   leg-muscles,   to   which   may  be 
added    the    jars   which    are    constantly 
given    to    the    column    of    blood    thus 
formed. 

Pathology.  —  The  structure  of  a  sac- 
culated aneurism,  from  mthout  inward, 
is  as  follows: — - 

1.  An  adventitious  sac  formed  of  con- 
densed areolar  tissue. 


ANEURISM.    PATHOLOGY. 


303 


2.  The  real  sac,  which  may  consist 
of  the  thickened  external  coat  and,  per- 
haps, a  portion  of  the  middle  coat  (false 
aneurism)  or  of  all  the  coats  (true  aneu- 
rism). The  atheromatous  and  calcareous 
patches  may  serve  to  distinguish  the  in- 
ner and  middle  coats. 

3.  Concentric  decolorized  fibrinous  lay- 
ers, harder  and  drier  toward  the  exterior 
and  toward  the  interior  softer  and  redder. 

4.  A  soft,  currant-jelly  coagulum, 
which  may,  however,  be  formed  previ- 
ous to  or  after  death. 

The  fibrinous  deposit  on  the  wall  of 
the  sac  acts  favorably  by  diminishing 
the  dilating  force  of  the  circulation  in 
the  sac  and  by  strengthening  the  wall. 
The  mouth  of  the  sac  is  round  or  oval, 
and  measures  much  less  than  a  section 
of  the  sac. 

If  the  contents  of  the  sac  be  exam- 
ined they  will  be  seen  to  vary  according 
to  the  stage  of  the  disease.  The  wall  of 
the  sac  is  very  thin  in  the  first  stage, 
and  contains  fluid  blood  only;  in  the 
second  stage  the  centre  only  of  the  sac 
will  contain  fluid  blood,  around  which 
are  placed  laminae  and  fibrin;  at  the 
periphery  a  much  thicker  wall  of  fibrin 
is  present.  The  laminse  of  fibrin  next 
to  the  wall  are  dry,  friable,  and  opaque, 
while,  as  the  centre  of  the  aneurism  is 
approached,  they  are  soft  and  red. 

Fibrin  is  rapidly  deposited  in  sac- 
culated aneurism,  being  more  rapidly 
formed  where  the  obstruction  to  the 
free  passage  of  the  blood  into  and  out 
of  the  sac  is  greater. 

Many  sacculated  aneurisms  are  prob- 
ably true  aneurisms  at  first,  but,  on  in- 
creasing in  size,  the  inner  coats  of  the 
artery  rupture  and  the  aneurism  becomes 
a  false  aneurism. 

In  tubular  or  fusiform  aneurism  the 
vessel  is  also  elongated.    Several  tubular 


aneurisms  may  exist  in  the  course  of  the 
same  vessel,  the  artery  remaining  healthy 
between  them. 

In  tubular -aneurism  the  three  coats  of 
the  artery  are  preserved,  but  the  middle 
coat,  not  undergoing  hyperplasia,  its  ele- 
ments no  longer  form  a  continuous  layer, 
but  are  separated  one  from  another.  The 
sac,  in  this  form  of  aneurism,  being,  in 
realit}^,  only  an  enlargement  of  the  lumen 
of  the  vessel,  exposed  to  the  full  current 
of  the  blood,  no  laminated  fibrin  is  found 
in  it. 

As  compared  to  other  tissues,  the  skin 
resists  longest  the  pressure  from  aneu- 
rism. 

Aneurisms  are  most  common  in  the 
thoracic  aorta  (ascending  and  transverse 
portions)  and  next  in  the  popliteal,  ca- 
rotid, subclavian,  innominate,  and  axil- 
lary. The  most  important  aneurisms  on 
small  arteries  are  those  in  the  brain, 
lungs,  and  heart. 

Case  of  aneurism  at  apex  of  heart ; 
the  patient,  'a  woman,  86  years  of  age, 
had  never  complained  of  any  cardiac 
trouble,  and  death  resulted  from  apo- 
plexy. The  autopsy  showed  a  small  an- 
eurism at  the  apex  of  the  heart,  with 
complete  absence  of  cardiac  muscle  at 
the  apex  of  the  left  ventricle.  There 
was  a  replacement  fibrosis  at  this  point. 
Some  parts  were  quite  calcareous,  and 
there  was  also  slight  interstitial  myo-- 
carditis.  The  coronary  artery  was  the 
seat  of  atheroma.  Larkin  (Med.  Eecord, 
Aug.  28,  '97). 

Case  of  multiple  aneurism  of  pulmo- 
nary artery  in  a  boy,  aged  12  years,  in 
whom  a  loud,  roai-ing,  pulmonary  sys- 
tolic bruit  and  very  highly-accentuated 
second  sound  were  present  during  life, 
with  haemoptysis,  epistaxis,  and  dropsy. 
Four  of  the  secondary  branches  in  one 
lung  and  three  in  the  other  led  into 
aneurisms  as  large  as  walnuts,  filled  with 
blood-clot.  The  boy  had  been  ill  for  a 
year.  Churton  (Brit.  Med.  Jour.,  May 
15,  '97). 


304 


ANEURISM.    PROGNOSIS. 


Case  of  hepatic  aneurism  in  which 
the  clinical  picture  included  pains  in 
the  right  hypochondrium  or  epigastrium, 
intermittent  jaundice,  and  repeated, 
profuse  haemorrhages  from  the  upper 
part  of  the  bowel.  The  diagnosis  is 
made  but  seldom,  and  cholelithiasis  or 
duodenal  ulcer  is  generally  thought  of, 
especially  since  all  three  symptoms  do 
not  always  occur  together.  The  most 
constant  of  these  is  the  pain.  In  the 
pathogenesis  trauma  plaj's  an  important 
role,  and  rather  often  there  is  a  history 
of  some  jjreceding  infectious  disease. 
A.  Sommer  (Prager  med.  Woch.,  Sept. 
8,  1902). 

Prognosis. — Spontaneous  recovery  oc- 
curs but  seldom;  a  deposit  of  fibrin  due 
to  a  slow  current  takes  place  in  the  sac 
and  completely  fills  it,  forming  a  firm 
and  solid  mass.  The  process  may  extend 
still  further  into  the  artery,  thus  ren- 
dering the  cure  still  more  secure.  The 
formation  of  an  embolus  is  only  to  be 
expected,  however,  when  the  diseased 
artery  is  small.  Spontaneous  recovery 
may  occur  in  other  ways:  from  a  clot 
being  washed  out  of  the  sac  into  the 
arterj^,  forming  an  embolus  which  com- 
pletely arrests  the  current  in  the  sac,  the 
latter  being  filled  with  a  firm  coagulum. 

The  sac  may  also  be  heavy  enough 
and  so  situated  as  to  stop  the  current 
•of  the  blood  in  the  artery  by  causing 
flexion  of  the  aneurismal  neck. 

In  some  cases  inflammation  of  the  sac 
and  coagulation  of  the  blood  contained 
in  it  also  effect  a  spontaneous  cure. 

Only  small  aneurisms  are  cured  by 
spontaneous  formation  of  a  thrombus  in 
the  sac  and  its  conversion  into  cicatricial 
tissue. 

Death  may  result  in  various  ways: — 

1.  By  rupture  of  the  sac.  In  this  case 
death  may  occur  instantly,  if  the  opening 
be  into  a  serous  cavity,  one  of  the  pleural 
cavities  (generally  the  left),  or  into  the 


pericardial    or    peritoneal    cavities,    the 
serous  membrane  giving  way  in  a  rent. 

Ten  cases  of  sudden  death  due  to  rupt- 
ure of  thoracic  aneurisms  previously 
unsuspected.  Deaths,  although  sudden, 
not  instantaneous;  sometimes  consider- 
able period  may  intervene.  F.  W.  Draper 
(Boston  Med.  and  Surg.  Jour.,  Mar.  14, 
'95). 

Cases  of  rupture  of  intrathoracic  aortic 
aneurisms  met  Avith  in  the  Pathological 
Department  of  the  Manchester  Royal 
Infirmary. 

Number  and  proportion  of  cases: 
Among  the  last  4593  cases  submitted  to 
pathological  examination  rupture  of  a 
thoracic  aneurism  has  been  noted  in  32 
cases.  This  gives  a  percentage  in  all 
"general"  cases  of  0.G9. 

Sex:  Of  the  32  cases,  30  were  men  and 
only  2  women;  that  is,  a  percentage  of 
93.75  males  and  6.25  females. 

Age:  The  exact  age  was  obtained  in 
30  of  the  cases;  the  others  were  middle- 
aged  males.  The  average  was  40  years. 
The  males  averaged  40.4  years.  The 
females  averaged  34  years.  The  young- 
est subject  was  aged  20  years  and  the 
oldest  was  aged  65  years. 

Seat  of  aneurism:  In  many  instances 
the  greater  part  of  the  arch  was  involved. 
Grouped,  however,  according  to  the  chief 
area  of  affection,  they  may  be  arranged 
as  follows:  Ascending  portion  of  arch, 
12;  transverse  portion  of  arch,  11; 
descending  portion  of  arch,  4;  and 
descending  thoracic   aorta,   5. 

Point  of  rupture:  This  can  be  best 
indicated  in  tabular  form:  — 


P.vRT  Ruptured  i 


Pleni-!i  (riglit) 

Lung  (left)  

Bronchus  (right).. 


No.  OF  Cases.      Percentage, 


Nature  of  death :  Of  the  thirty-two 
cases,  six  were  observed  in  medico-legal 
investigations,  the  subjects  being  brought 


ANEURISM.    TREATMENT. 


305 


dead  to  the  hospital,  having  been  found 
dead  or  suddenly  seized  in  the  street  or 
elsewhere.  In  one  instance  a  man,  while 
riding  in  a  cart,  suddenly  fell  out  of 
the  vehicle  and  was  picked  up  dead.  Id 
nearly  all  the  eases  where  rupture  oc- 
curred while  in  hospital  or  where  a 
clear  history  could  be  obtained  death 
was  sudden,  in  many  instances  being 
practically  instantaneous.  In  one  case, 
where  rupture  occurred  into  the  oesoph- 
agus, death  took  place  in  five  minutes. 
In  another,  where  the  aneurism  burst 
into  the  pericardium,  the  patient  felt 
faint  and  was  dead  in  three  minutes. 
In  one  subject,  where  the  pericardium 
was  found  filled  with  blood,  and  where 
there  was  commencing  erosion  into  the 
trachea,  with  also  extension  into  the  left 
lung,  a  small  quantity  of  frothy  blood 
was  brought  up  for  some  hours  before 
death,  which  was  sudden.  In  a  ease 
where  there  was  general  aneurismal  dila- 
tation of  the  arch  of  the  aorta,  rupture 
took  place  into  the  pericardium  through 
a  vertical  slit  two  and  a  third  inches 
in  length.  The  patient  was  brought  to 
the  hospital  in  what  appeared  to  be  a 
syncopal  attack,  and  died  suddenly  four 
hours  later.  In  one  case  where  death 
occurred  suddenly,  blood-clot  weighing 
eighty-five  ounces  was  found  in  the  left 
pleural  cavity.  T.  N.  Kelynack  (Lancet, 
July  24,  '97). 

Death  is  not  so  rapid  when  the  aneu- 
rism reaches  to  the  skin  or  to  a  mucous 
membrane,  such  as  the  trachea,  oesopha- 
gus, intestine,  or  bladder. 

The  rupture  of  an  aneurism  through 
a  mucous  surface  occurs  by  the  forma- 
tion of  a  small,  circular  abscess;  through 
a  serous  surface  the  rupture  is  by  a  iis- 
sured  or  star-like  opening.  In  the  skin 
a  small  slough  is  formed,  which,  on  fall- 
ing, leaves  a  minute  opening,  through 
which  the  blood  passes.  This  is  soon 
arrested  by  clotting,  but  the  haemor- 
rhage soon  recurs  and  death  is  finally 
caused  by  repeated  hemorrhages. 

2.  Death  may  occur  from  the  compres- 
sion of  important  organs.    Pressure  upon 

1- 


I  the  trachea,  bronchi,  or  lungs  causes  suf- 
focation; upon  the  oesophagus  or  tho- 
racic duct  inanition. 

In  tubular  aneurisms  death  may  be 
caused  by  syncope  due  to  impediment  to 
the  circulation  or  by  compression  of  the 
oesophagus  or  bronchi  or  by  rupture  into 
the  pericardium. 

When  the  vertebrje  and  ribs  are  com- 
pressed these  bones  are  absorbed  and 
spinal  irritation  and  even  meningitis  are 
produced.  Pressure  upon  the  intercostal 
nerves  gives  rise  to  severe  neuralgia. 

3.  Inflammation  and  suppuration  of 
the  sac  may  cause  death  by  inducing 
septicaemia  and  pytemia. 

4.  If  the  aneurism  is  in  the  arch  of 
the  aorta  a  clot  may  be  carried  to  the 
brain  by  the  cerebral  arteries,  causing 
embolism  and  death. 

5.  Gangrene  of  an  extremity  caused 
by  obstruction  may  cause  death  by  septic 
infection. 

A  sacculated  aneurism  usually  forms 
upon  a  tubular  aneurism  and  causes 
death  more  rapidly  than  the  tubular 
aneurism  alone  would  have  done. 

Duration  of  An&urism.  —  Though  an 
aneurism  may  grow  very  rapidly,  it  lasts 
several  years,  in  the  majority  of  cases. 
So  long  as  the  cause  is  present  it  tends 
to  develop. 

The  various  causes  which  influence 
the  duration  of  an  aneurism  are  its  situ- 
ation, the  size  of  the  mouth  of  the  sac, 
the  condition  of  the  latter,  the  force  of 
the  blood-current,  the  state  of  the  blood 
as  to  coagulation,  and  the  mode  of  life 
of  the  patient. 

Treatment  of  Aneurisms  in  General. — 
Obliteration  of  the  sac  and  occlusion  of 
the  afferent  and  efferent  vessels  are  the 
aims  to  be  reached. 

The  best  results  may  frequently  be  ob- 
tained by  combining  several  modes  of 
treatment. 

20 


306 


ANEURISM.    TREATMENT. 


Obliteration  of  the  sac  can  be  obtained 
by  diminishing  the  force  of  the  circula- 
tion of  the  blood  in  it,  thus  encouraging 
coagulation. 

TuFFNELL^s  METHOD.  —  The  bcst- 


known  method  in  this  connection  is  that 
of  TufEnell,  which,  though  usually  em- 
ployed for  internal  aneurisms,  has  also 
been  advantageously  used  for  aneurisms 
of  the  extremities. 


Fig.  2. 
Pathological  speeimena  of  ruptured  aneurisms.     {Scarpa.) 

Fig.    1.— Ruptured   aortic   aneurism,     a,   Thoracic   aorta   stripped   of   its   pleura   and 

cellular  coat:    c,  c,  Rupture  of  the  posterior  wall  of  the  aorta;    f,  Aneurismal  sac 

covered  by  the  pleura;    h,  Rupture  of  the  aneurismal  sac. 
Fig.  2.— Ruptured  aneurism  of  the  arch  of  the  aorta.     6,  h,  Bottom  of  cavity  showing 

the  location  of  the  rupture  of  the  artery. 
Fig.  3.— Ruptured  carotid  aneurism.     I,  Inferior  orifice  of  left  carotid  artery,  ruptured ; 

m,  Superior  orifice  of  the  left  carotid  artery;    h,  Right  carotid;    r,  Aneurismal  sac. 
Fig.   4.— Ruptured   popliteal   aneurism,      a,   a,   Ruptured   popliteal   aneurism   farther 

opened;    6,  Artery;    c,  Superior  orifice  of  artery;    d,  d.  Portion  of  aneurism  torn. 


ANEURISM.     TREATJIENT. 


307 


The  object  of  Tuffnell's  treatment  is 
to  reduce  the  watery  elements  of  the 
blood  and  to  increase  the  solid  elements. 

The  patient  is  kept  in  the  recumbent 
position  for  at  least  three  months;  this 
causes  the  rate  of  pulsation  to  diminish 
greatly.  In  one  case  it  fell  in  a  few 
days  from  96  to  66:  a  reduction  of  30 
beats  a  minute,  1800  beats  an  hour,  and 
43,200  beats  a  day.  No  drug  can  cause 
such  a  diminution  without  danger  to 
the  patient.  The  recumbent  position, 
according  to  TufEnell,  acts  upon  the  cir- 
culation in  internal  aneurism  as  does 
mechanical  compression  in  external  aneu- 
rism. The  food  is  diminished,  amount- 
ing to  but  10  ounces  of  solid  and  6 
ounces  of  fluid  in  the  twenty-four  hours. 

TufPnell's  food  consists  of  2  ounces  of 
bread  and  butter  and  2  ounces  of  milk 
for  breakfast;  2  or  3  ounces  of  meat 
and  3  or  4  ounces  of  milk  or  claret  for 
dinner;  2  ounces  of  bread  and  2  ounces 
of  milk  for  supper. 

Best  and  restriction  of  liquids  are  the 
most  important  parts  of  the  treatment. 

Tuilnell  published  his  first  observa- 
tions in  1875.  Of  ten  cases  treated  seven 
were  cured  and  three  died  during  the 
treatment.  One  case  of  popliteal  aneu- 
rism made  a  recovery  in  twelve  days. 

To  induce  sleep  lactuearium  is  recom- 
mended, and,  with  the  view  of  dimin- 
ishing the  liquid  portion  of  the  blood, 
the  patient  is  purged  from  time  to  time 
with  compound  powder  of  jalap. 

Results  of  study  of  effect  upon  tlie 
blood  of  Tuffnell  method  of  treatment, 
combined  with  calcium  salts,  in  manage- 
ment of  two  cases  of  aortic  aneurism. 
Restriction  of  fluids  caused  decrease  in 
elimination  of  calcium  salts,  while  in- 
crease of  fluids  caused  marked  increase 
in  their  elimination.  Water  should  be 
given  in  abundance,  if  it  is  desired  to 
saturate  the  body  with  calcium  salts. 
Personal  cases  absorbed  much  more  cal- 


cium while  taking  laige  quantities  of 
water.  Ingestion  of  calcium  seemed  to 
increase  the  quantity  in  the  circulating 
blood.  Specific  gravity  of  blood  was  not 
distinctly  affected  by  the  treatment. 
The  plasma-nitrogen,  plasma-albumin, 
and  the  quantity  of  albumin  in  the 
plasma  of  100  cubic  centimetres  of  blood, 
were  constant  in  the  two  cases,  except 
at  one  estimation.  The  fibrin-nitrogen 
was  not  increased.  The  time  of  coagula- 
tion was  reduced  in  one  case,  but  was  not 
aflected  by  the  ingestion  of  calcium.  In 
the  other  case  the  time  varied,  but  was 
not  shortened  on  the  average.  Influence 
of  the  treatment  upon  the  blood  seemed, 
therefore,  entirely  negative,  although  ■ 
both  patients  showed  distinct  improve- 
ment in  their  physical  signs.  A.  E.  Tay- 
lor (Jour.  Exper.  Med.,  May,  '98). 
Medicinal  Teeatment.  —  With  the 
idea  that  aneurism  is  often  due  to  syph- 
ilis, iodide  of  potassium  has  been  much 
employed;  its  probable  action  is  that  of 
depressing  the  heart. 

The  assertion  that  iodide  of  potassium 
has  the  power  of  lowering  blood-pressure 
is  contradicted  by  the  sphygmomanom- 
eter. Alexander  James  (Brit.  Med.  Jour., 
June  29,  '95). 

The  cases  reported  in  which  iodide  of 
potassium  has  been  of  benefit  do  not 
sustain  the  credit  accorded  that  drug  as 
a  curative  agent;  still  it  ought  to  be 
tried  in  cases  where  there  is  even  but  a 
suspicion  of  syphilitic  taint.  Bristow 
(Brooklyn  Med.  Jour.,  Oct.,  '95). 

[It  may  further  be  said  that  the  drug 
usually  seems  to  promote  the  comfort  of 
the  patient:  a  factor  of  considerable  im- 
portance in  the  treatment  of  a  chronic, 
incurable,  and  often  distressing  disease. 
Whittieb  and  Vickery,  Assoc.  Eds., 
Annual,  '96.] 

In  cases  which  have  a  history  of  syph- 
ilis, iodide  of  potassium  internally  and 
mercury  as  an  inunction  recommended. 
For  some  weeks  afterward  the  patient  is 
kept  in  bed  and  fed  chiefly  with  milk. 
Over  the  situation  of  the  aneurism  an 
ice-bag  is  applied  several  times  a  day  for 
hours.  The  results  of  this  treatment 
have,  on  the  whole,  been  so  favorable  as 


308 


ANEURISM.    TREATMENT. 


to  wan-ant  the  use  of  mercurial  inunc- 
tion in  oases  without  a  history  of  syph- 
ilis. A  rapid  subsidence  of  dyspnoea 
and  bronchostenosis  was  obtained,  the 
relief  continuing  sufficiently  long,  in 
some  instances,  to  permit  patients  re- 
suming their  occupation.  A.  Fraenkel 
(Deutsche  med.  Woch.,  Feb.  4,  '97). 

Case  of  non-syphilitic  aneurism  in 
which  30  to  60  grains  of  iodide  of  potas- 
sium per  day,  and  an  ice-bag  applied  to 
the  tumor,  caused  the  pulsation  to  di- 
minish, and  in  five  months  the  patient, 
a  street-singer,  was  able  to  resume  his 
occupation.  Edouard  (Revue  de  Med., 
May   10,  '97). 

The  calcium  salts  have  been  recom- 
mended. 

Four  cases  of  aneurism  in  which  the 
amount  of  calcium  salts  passed  in  the 
urine  was  much  greater  than  normal; 
may  be  useful  as  an  aid  to  diagnosis. 
E.  Reale  (Rivista  clinica  e  terapeutica, 
Naples,  Nov.,  '91;  Brit.  Med.  Jour.,  Mar. 
26,  '92). 

Marked  improvement  from  hydrated 
calcium  chloride  in  doses  of  1  drachm 
daily.  Solomon  Solis-Cohen  (Philadel- 
phia Polyclinic,  July  6,  '95). 

Acetate  of  lead  lias  been  used  to 
"equalize  the  circulation,"  and  bromide 
of  potassium  is  frequently  employed 
against  the  cough  and  pain. 

Gallic  acid,  iron  sulphate,  barium  chlo- 
ride, digitalis,  veratrum  viride,  and  aco- 
nite have  been  used,  but  the  majority  of 
clinicians  do  not  look  upon  these  agents 
with  favor. 

Coagulating  Inj&ctions.  —  These  have 
been  utilized  for  aneurisms  of  the  ex- 
tremities. Tannin,  lead  acetate,  Monsel's 
solution  of  iron,  spermaceti  (Dobell),  and 
other  drugs  being  used. 

Cervical  aneurisms  should  not  be 
treated  by  these  injections,  lest  an  em- 
bolus be  carried  to  the  brain. 

To  prevent  emboli  being  carried  into 
the  circulation  the  arteries  above  and  be- 
low the  aneurism  should  be  compressed 


both  during  the  operation  and  for  some 
time  after  it.  In  the  opinion  of  Till- 
mann,  any  treatment  by  injection  is  dan- 
gerous. 

Gelatin  Injections. — Injections  of  liq- 
uid gelatin  have  recently  been  advocated 
even  in  desperate  cases. 

Operative  technique  of  injection  of 
gelatin  for  treatment  of  aneurism  is  as 
follows:  White  gelatin  in  a  quantity  of 
from  1  drachm  to  1  V4  drachms  is  dis- 
solved in  a  7-per-cent.  solution  of  sodium 
chloride  in  measure  1  to  2  quarts.  The 
solution  is  placed  in  a  flask,  which  is 
sealed  and  then  sterilized  with  its  con- 
tents at  a  temperature  of  120°  C.  For 
the  injection  a  flask  of  the  capacity  of  1 
pint  is  got  ready,  fitted  with  a  cork  and 
two  tubes  like  a  wash-bottle.  The  long 
tube  is  connected  with  a  sterilized  needle 
and  the  short  tube  with  an  India-rubber 
air-ball.  The  gelatin  is  liquefied  in  a 
water-bath  at  a  temperature  of  95°  F. 
and  poured  into  the  flask,  which  is  also 
kept  in  a  water-bath.  The  injection  is 
made  slowly  into  the  subcutaneous  tis- 
sues of  the  buttock  and  should  take 
fifteen  minutes.  It  should  be  repeated 
every  six  or  eight  days  until  the  sac  is 
obliterated.  This  method,  if  carried  out 
with  care,  gives  excellent  results  in  the 
most  desperate  eases.  Lancereaux  (Paris 
Academy  of  Med.;    Lancet,  Nov.  19,  '98). 

Injections  of  gelatin  in  aneurism.  Case 
of  aortic  aneurism  in  which  the  size  of 
the  tumor  was  much  reduced  after  10 
injections  (1V=  ounces  each)  of  gelatin 
solution.  The  following  formula  is  sug- 
gested:— 

1}   White  gelatin.  15  grains. 
Salt,  7  V;  grains. 
Hot  water,  26  ounces. 

This  mixture  is  sterilized  and  allowed 
to  cool.  When  required  for  use  it  is 
warmed  to  fluidity  and  injected  under 
the  skin  with  antiseptic  precautions. 
The  injections  may  be  given  every  few 
days,  or  even  every  day.  After  the  in- 
jections the  patients  should  remain  abso- 
lutely quiet  in  bed.  Frankel  (Deut.  med. 
Presse,  June  9,  '99). 


ANEURISM.    TREATMENT. 


309 


Nine  cases  treated  with  gelatin  sug- 
gest the  following  conclusions:  1.  In  no 
case  did  cure  of  the  aneurism  result,  and 
only  in  one  was  there  considerable  im- 
provement. 2.  In  seven  cases  there  was 
an  appreciable  lessening  of  the  pressure 
symptoms.  3.  The  coagulability  of  the 
blood  is  greatly  increased.  4.  The  injec- 
tions often  cause  a  good  deal  of  pain. 
5.  The  injections  are  sometimes  followed 
by  rigor  and  fever.  6.  The  treatment 
affords  amelioration,  and  is  deserving  of 
further  trial.  Futcher  (Jour.  Amer.  Med. 
Assoc,  Jan.  27,  1900). 

Treatment  of  aneurisms  with  gelatin 
in  several  recent  cases.  Complete  cure  of 
a  large  aneurism  by  total  obliteration  of 
the  sac  is  obtained  only  after  a  variable 
number  of  injections  of  gelatin,  accord- 
ing to  the  ease,  but  approximately  from 
25  to  30  at  the  least.  Lancereaux  and 
Paulesco  (Gaz.  des  Hop.,  July  17,  1900). 

Three  cases  of  thoracic  aneurism 
treated  by  gelatin  injections.  They  were 
under  observation  in  the  Hudson  Street 
Hospital.  None  of  them  was  successful. 
The  cases  were  not  under  observation 
long  enough  to  give  data  for  a  final  con- 
clusion, but  the  result  seems  sufficient 
to  indicate  that  gelatin  injections  not 
only  do  no  good,  but  cause  severe  pain 
locally  and  often  considerable  constitu- 
tional reaction.  Lancereaux's  method 
was  to  take  1  to  1  V.i  drachms  of  gelatin 
and  make  a  solution  of  it  in  200  cubic 
centimetres  of  normal  salt  solution.  This 
was  kept  for  several  days  at  a  tempera- 
ture of  38°  C.  If  no  cloudiness  developed 
nor  any  other  sign  of  micro-organismal 
growth  the  liquid  was  injected  sub- 
cutaneously,  usually  into  the  patient's 
thigh.  After  about  a  week  another  in- 
jection was  made  and  the  treatment  con- 
tinued at  regular  intervals.  Special  di- 
rections were  given  by  Lancereaux  not 
to  palpate  the  aneurism  during  the 
course  of  the  treatment.  At  first,  a  2- 
per-cent.  solution  of  gelatin  was  used; 
later,  however,  he  used  a  1-per-cent.  so- 
lution. Attention  is  called  to  the  fact 
that,  if  Lancereaux's  directions  were 
followed,  the  patient  would  be  given 
twenty  injections  covering  a  period  of 
five  months.  During  all  this  time  the 
patient  should  rest  in  bed.    Rest  is  suffi- 


cient of  itself  to  relieve  greatly  the  sub- 
jective symptoms  of  aneurism,  and  often 
does  away  with  certain  of  the  physical 
signs  and  even  lessens  the  size  of  the 
aneurism.  Lewis  A.  Conner  (Med.  News, 
Aug.  11,  1900). 

The  injections  are  often  followed  by 
fever  and  pain.  The  possibility  of  ex- 
tensive coagulation  and  of  embolism  has 
not  been  demonstrated.  The  injections 
may  cause  increase  of  vascular  pressure 
and  involve  rupture  of  a  large-sized 
aneurism  whose  walls  are  thin.  The 
clinical  observations  so  far  made  do  not 
warrant  an  exact  estimate  of  the  value 
of  the  gelatin  treatment.  Henri  Grenet 
and  G.  Piquard  (Archives  Gfinerales  de 
M6d.,  June,  1901). 

It  has  also  been  affirmed  that  the 
gelatin  method  is  painful  and  liable  to 
cause  fever,  but  if  the  solution  be  gently 
injected  into  the  subcutaneous  tissue  of 
the  thigh,  it  is  absolutely  painless,  an-d 
if  proper  antiseptic  precautions  are  ob- 
served there  is  no  fever.  The  authors 
insist  upon  these  details,  as  showing 
that  the  ill  success  attributable  to  this 
method  of  treatment  depend  entirely  on 
a  faulty  technique.  Lancereaux  and 
Paulesco  (Bull.  Acad,  de  Mgd.,  Paris, 
July  16,  1901). 

Suicutaneous  Injections. — Langenbeck 
recommends  subcutaneous  injections  of 
ergotine,  which  act  in  two  ways:  by  slow- 
ing the  action  of  the  heart,  thus  favoring 
the  deposit  of  fibrin,  and  causing  con- 
traction of  the  unstriped  muscular  fibre 
entering  into  the  composition  of  the 
middle  coat  of  the  artery,  thus  raising 
the  blood-presstire. 

CoMPEESSiON. — Compression  was  used 
over  two  hundred  years  ago  for  cases 
of  traumatic  aneurism,  but  the  first  sur- 
geon to  propose  this  method  was  Heister. 
In  1772  Guattani,  an  Italian,  compressed 
the  entire  limb  and  the  sac  in  cases  of 
popliteal  aneurism.  Cases  thus  treated 
usually,  however,  ended  fatally,  from 
transformation  of  the  circumscribed  an- 
eurism into  a  diffuse  aneurism,  inflam- 
mation and  suppuration  of  the  sac,  and 


310 


ANEURISM.     TREATMENT. 


gangrene  of  the  leg.  The  mortality  was 
50  per  cent. 

John  Hunter,  in  1785,  introduced 
into  the  treatment  of  aneurism  the  gov- 
erning principle  that  the  current  of  the 
blood  through  the  sac  should  not  be 
completely  suppressed,  but  only  dimin- 
ished, thus  allowing  the  elasticity  of  the 
sac  to  act.  In  this  way  the  effect  of  the 
overpressure  from  the  heart's  action  is 
removed. 

The  fact  that  the  sac  in  diffused  and 
traumatic  aneurism  is  not  contractile 
explains  why  this  treatment  is  without 
success  in  aneurisms  of  this  variety. 

Advantages  of  compression  over  liga- 
tion:— 

1.  It  is  not  so  dangerous;  if  neces- 
sary, it  can  be  discontinued  and  then 
renewed,  whereas,  in  ligation,  the  danger 
may  be  great  for  many  days  following 
the  operation. 

2.  In  cases  treated  by  compression 
only  the  sac  consolidates,  just  as  in 
spontaneous  cure.  The  arteries,  up  to 
the  point  of  compression,  are  not  con- 
solidated, as  in  ligation. 

3.  Compression  is  more  successful  than 
ligation,  and  does  not  present  danger  of 
complications,  such  as  secondary  haem- 
orrhage, sloughing  of  the  sac,  phlebitis, 
gangrene,  or  pyaemia. 

4.  Ligation  has  been  followed  by  a 
second  aneurism  or  by  suppuration  in 
the  sac.  Though  these  complications 
may  occur  after  compression,  they  are 
not  likely  to  do  so,  and  consequently 
compression  is  more  likely  to  be  perma- 
nent than  ligation. 

Compression  may  be  applied  with  the 
fingers  or  by  means  of  various  instru- 
ments, bags  of  shot,  Esmarch's  elastic 
bandage,  flexion  of  the  joints,  etc. 

Jonathan  Knight,  of  New  Haven, 
Conn.,  first  employed  the  finger  as  a 
means  of  compression  in  1848,  and  in 


the  same  year  Willard  Parker  and  James 
R.  Wood,  of  New  York  City,  each  suc- 
cessfully treated  an  aneurism  in  this 
manner. 

Digital  pressure  over  the  vessel,  Just 
above  the  aneurism,  is  applied  by  a 
succession  of  assistants  relaying  one  an- 
other. The  procedure  is  rendered  much 
less  irksome  for  the  operator  by  placing 
a  weight  upon  the  pressing  fingers,  the 
muscular  strain  being  thus,  in  a  meas- 
ure, relieved. 

It  is  necessary  to  keep  up  the  press- 
ure from  one  to  several  days,  until  the 
pulsation  has  ceased.  The  average  time 
required  is  three  days.  The  pressure 
should  then  be  gradually  diminished,  in 
order  to  prevent  disintegration  of  the 
clot  before  it  is  firmly  contracted. 

In  proximal  compression  of  the  artery 
it  is  only  necessary  to  stop  the  pulsation 
of  the  sac,  it  being  unnecessary  to  stop 
the  flow  of  blood  through  it.  This 
method  succeeds  best  in  sacculated  aneu- 
risms. In  tubular  aneurisms  it  causes 
gradual  contraction,  but  not  by  a  deposit 
of  fibin. 

When  the  sac  contains  fluid  blood 
only,  the  chances  of  success  are  more 
favorable.  In  an  already  partly-filled 
sac  coagulation  may  be  too  sudden  and 
imperfect. 

Recovery  is  shown,  when  compression 
above  the  sac  has  been  resorted  to,  by 
cessation  of  pulsation  in  the  sac  when 
pressure  is  removed,  by  no  thrill  or  bruit 
being  present,  and  by  the  development 
of  a  collateral  circulation. 

The  collateral  circulation  which  de- 
velops after  the  sac  has  been  filled  with 
fibrin  indicates  that  the  sac  has  been 
obliterated. 

Sudden  enlargement  of  the  collateral 
circulation,  occurring  both  in  cures  hap- 
pening spontaneously  and  in  those  due 
to  compression,  may  cause  considerable 


ANEURISM.     TREATMENT. 


311 


pain.      The    latter,    therefore,    may    be 
looked  upon  as  a  favorable  symptom. 

In  aneurisms  of  the  extremities  and 
neck  compression  gives  good  results. 
This  causes,  wlien  cure  takes  place,  the 
formation  of  coagula  in  the  aneurismal 
sac,  through  or  alongside  of  which,  how- 
ever, a  canal  remains  through  which  the 
blood  passes.  The  coagula  shrink  grad- 
ually and  become  more  solid  and  firmly 
adherent  to  the  inner  wall  of  the  aneu- 
rismal sac.  Compression  can  be  carried 
out  only  with  intelligent  patients.  Bill- 
roth (Wiener  klin.  Woch.,  No.  50,  '93). 
[When  compression  has  ultimately  to 
be  abandoned,  its  temporary  use  is  of 
advantage  in  so  far  as  it  prepares  the 
way  for  establishment  of  the  collateral 
circulation.  John  H.  Packard,  Assoc. 
Ed.,  Annual,  '92.] 

Compression  by  means  of  the  contrac- 
tile power  of  ordinary  collodion,  in  small 
aneurisms;      successful    in    three    cases. 
Williams      (Amer.     Mcdieo-Surg.     Bull., 
Apr.,  '93). 
Compression  hj  the  Esmarch  Bandage. 
— In  this  method  it  is  sought  to  produce 
red  blood-clot,  such  as  is  formed  when 
the  blood  no  longer  circulates,  and  not 
the  fibrinous,  or  white,  blood-clot,  such 
as  is  formed  when  the  blood  is  in  mo- 
tion.    Such  a  clot  contracts,  but  does 
not  become  organized,  and  acts  mainly 
by  forming  a  thrombus  in  the  afferent 
and  efferent  vessels. 

Pressure  by  means  of  an  Esmarch 
bandage  was  first  successfully  employed 
by  Eeid,  of  the  British  navy,  in  1875, 
though  in  1864  Murray  had  already 
succeeded  in  treating  an  aneurism  of 
the  abdominal  aorta  by  anesthetizing 
the  patient  and  checking  the  circulation 
completely  by  means  of  an  instrument. 
The  patient  should  first  be  given  an 
hypodermic  injection  of  morphine,  then 
just  enough  ether  as  an  anaesthetic  to 
prevent  pain  and  insure  quiet. 

After  placing  a  piece  of  chamois-skin 
over  the  artery  to  prevent  chafing,  the 
limb  is  firmly  wrapped  in  an  elastic  band- 


age from  its  extremity  up  to  the  tumor; 
the  latter,  however,  is  lightly  covered 
over;  but,  as  soon  as  it  is  passed,  the 
bandage  is  again  firmly  applied,  thus 
allowing  a  certain  amount  of  fluid  blood 
to  remain  in  the  sac. 

A  tourniquet  is  then  placed  above  the 
aneurism,  to  prevent  disintegration  of 
the  clot  in  the  sac  and  of  the  thrombi 
in  the  arteries  by  the  circulation,  and 
left  in  situ  from  sixteen  to  twenty-four 
hours.  The  pressure  is  then  gradually 
decreased  by  unscrewing  the  tourniquet, 
while  due  attention  is  paid  to  the  state 
of  the  circulation,  to  avoid  gangrene 
by  too  prolonged  pressure,  and  to  avoid 
disturbing  the  clot  before  it  is  solid. 

A  collateral  circulation  is  soon  formed. 
Danger  may  arise  in  some  cases  from  the 
sudden  rise  and  fall  of  blood-pressure  or 
from  rupture  of  the  sac;  pressure  on  the 
nerves,  gangrene,  and  momentary  renal 
disorders  are  possible  sequelae. 

Pressure  may  be  advantageously  aided 
by  the  administration  of  iodides  and  a 
limited  albuminous  diet. 

The  contra-indications  to  this  treat- 
ment are  vascular  degeneration  elsewhere 
than  in  the  aneurism,  renal  disease,  or 
inflammation  of  the  sac. 

But  few  appropriate  cases  in  which 
compression  in  some  form  has  been  faith- 
fully persevered  in  for  a  long  time  have 
been  unattended  with  improvement. 

The  method  of  applying  compression 
preferred  by  Tillmann  is  to  envelop  the 
limb  with  an  elastic  bandage  from  its 
extremity  up  to  near  the  aneurism  for 
about  an  hour  and  a  half;  a  tourniquet 
should  then  be  applied  above  the  aneu- 
rism, and  removed  with  the  bandage  an 
hour  and  a  half  later.  Digital  or  instru- 
mental compression  should  follow  for 
from  six  to  twelve  hours. 

Compression  hy  Flexion.  —  This 
method,    which    was   first   employed    in 


312 


ANEURISM.    TREATMENT. 


1858  by  Hart,  can  only  be  used  for  the 
arm  and  leg.  It  consists  in  bandaging 
the  entire  extremity,  and  then  flexing  it 
strongly:  the  forearm  upon  the  arm,  the 
leg  upon  the  thigh,  or  the  thigh  upon 
the  pelvis. 

The  effects  of  this  method  are  to  com- 
press the  sac  itself,  to  retard  the  circu- 
lation through  it,  and  occasionally  to 
cause  a  small  clot  to  be  dislodged,  by 
means  of  which  the  mouth  of  the  latter 
becomes  occluded. 

Flexion  of  the  joint  can  be  used  only 
in  aneurisms  of  small  or  medium  size; 
when  the  tumor  is  large  the  sac  might 
be  ruptured.  It  is  an  unsafe  procedure 
when  the  sac  is  inflamed  or  when  there 
is  much  cedema  of  the  leg. 

Flexion  is  especially  indicated  when 
the  tumor  is  of  small  size,  the  sac  not 
inflamed,  and  the  joint  not  involved. 

An  argument  in  favor  of  flexion  is 
that  if  unsuccessful  no  harm  follows  the 
procedure. 

Macewen's  Method. — The  object  of  this 
method  is  to  form  white  thrombi  within 
the  sac,  by  lightly  scratching  the  inter- 
nal surface  of  the  sac  with  needles  thrust 
through  the  previously-asepticized  wall. 
The  needles  are  thus  left  in  contact  with 
the  sac  xintil  the  entire  wall  has  thus 
been  lightly  irritated.  The  position  of 
the  needle-points  should  be  changed  at 
intervals  of  ten  minutes.  It  may  be  nec- 
essary to  continue  this  for  forty-eight 
hours,  the  sittings  being  repeated  from 
time  to  time  for  weeks  or  even  months. 
Besides  the  effect  upon  the  aneurismal 
currents  there  occur  an  infiltration  of 
the  parietes  with  leucocytes  and  a  seg- 
regation of  them  from  the  blood-stream 
at  the  point  of  irritation. 

The  advantage  of  white  thrombi  over 
the  red  is  in  the  less  marked  tendency 
of  the  former  to  shrink  in  volume  or  to 
undergo    penetration    by    leucocytes    or 


yellow  softening.  The  object  is  to  ob- 
tain an  adhesion  of  leucocytes  to  the 
vessel-wall,  and  to  promote  successive 
accretions  of  these  bodies  (a  parietal 
thrombus)  until  complete  occlusion  oc- 
curs. For  this  purpose  a  slender  pin  of 
sufficient  length  is  employed  to  transfix 
the  aneurism  and  to  permit  manipula- 
tion, in  order  to  scratch  the  inner  sur- 
face of  the  opposite  wall  at  various 
points  over  its  entire  extent.  Sometimes 
this  can  be  accomplished  by  one  inser- 
tion, but  it  may  be  necessary  to  thrust 
the  pin  in  at  several  points.  Antiseptic 
precautions  are,  of  course,  to  be  observed. 
The  length  of  time  during  which  the  pin 
is  to  be  kept  in  place  varies,  but  should 
never  exceed  forty-eight  hours,  and  may 
be  much  less.  In  the  case  of  a  very  large 
aneurism  several  pins  may  be  introduced 
at  various  points,  but  they  should  not 
be  too  close  together.  Every  aneurism 
contains  within  itself  a  potential  cure  as 
the  essential  matter,  whatever  may  be 
the  method  devised  for  inducing  its 
action.    Macewen  (Lancet,  Nov.  22,  '90). 

An  antiseptic  gauze  dressing  should 
be  applied  to  the  neighboring  region 
while  the  needle  is  left  in  the  sac. 

One  needle  usually  suffices,  but  it  may 
be  necessary  to  use  two  or  three. 

Any  superficial  ulceration,  inflamma- 
tion of  the  sac,  or  erysipelatous  indura- 
tion is  a  contra-indication. 

Needles  may  also  be  used  to  transfix 
the  aneurism  or  for  the  purpose  of  caus- 
ing coagulation,  as  in  electrolysis. 

In  acupuncture  very  fine  gilded  nee- 
dles are  introduced  into  the  sac,  crossing 
one  another,  and  thus  forming  a  centre 
around  which  the  blood  coagulates.  They 
are  removed  several  days  later.  This 
method  is  seldom,  if  ever,  successful. 

In  galvano puncture  two  insulated  nee- 
dles are  introduced  into  the  sac  at  about 
an  inch  apart,  and  being  brought  into 
contact  by  their  internal  extremities  a 
galvanic  current  is  passed  through  them. 
This  method  was  proposed  by  Phillips  in 
1829.    It  exposes  to  embolism,  suppura- 


ANEURISM.    TREATMENT. 


313 


tion  in  the  sac,  and  hasmorrhage  through 
the  needle-punctures. 

Electrolysis  Through  Introduced  Wire. 
—The  introduction  into  the  sac  of  fili- 
form material,  especially  wire,  as  recom- 
mended by  Moore  (see  below)  having 
given  evidences  of  value,  D.  D.  Stewart, 
of  Philadelphia,  showed  the  great  advan- 
tage of  combining  electrolysis  with  the 
introduction  of  wire  in  sacculated  aneu- 
risms, and  has  published  cases  in  which 
satisfactory  results  were  obtained.  The 
aneurisms  treated  were  not  susceptible 
of  cure  by  medical  or  surgical  means. 
The  procedure  is  a  distinct  advance  in 
curative  means. 

Final  report  of  a  ease  of  a  very  large 
innominate  aneurism  completely  cured 
by  the  employment  of  electrolysis 
through  ten  feet  of  snarled,  coiled,  fine, 
gold  wire,  introduced  into  the  sac; 
death  at  the  expiration  of  three  and  a 
half  years  from  cerebral  thrombosis. 
The  newer  method  consists  in  introduc- 
ing into  the  sac,  under  the  strictest  anti- 
septic precautions,  a  fine  silver  or  gold, 
coiled  wire,  previously  so  drawn  that  it 
may  be  readily  passed  through  a  thor- 
oughly insulated  needle  of  somewhat 
larger  calibre  than  the  wire  and,  after 
introduction,  assume  snarled  spiral  coils, 
that,  with  a  moderate  amount  of  wire, 
the  entire  calibre  of  the  sac  will  be 
reached,  unless  the  cavity  be  already 
filled  with  coagula  or  the  sac  be  of  un- 
usual size  (as  was  the  case  with  one 
aneurism  so  treated) . 

The  wire  must  be  neither,  in  amount 
or  calibre,  too  great  nor  too  bulky  or 
highly  drawn  that  the  results  to  be  de- 
sired be  interfered  with.  Nor  should  the 
wire  be  of  a  material  so  brittle  as  steel 
nor  of  hard-drawn  iron,  lest  fracture 
occur  in  process  of  contraction  of  sac, 
with  danger  of  rupture.  Nor  should  it 
be  of  soft  iron,  as  was  recommended  on 
theoretical  grounds  by  Stevenson;  for, 
with  the  last,  so  great  a  quantity  of 
detritus  will  result,  due  to  the  decom- 
position of  the  iron  and  the  formation 
of  insolub'e  salts  under  the  current's  in- 


fluence, even  with  low  amp6rage,  that 
danger  of  emboli  result. 

Silver  or  gold  wire  is  undoubtedly 
preferable  material. 

The  amount  of  wire  required  depends 
necessarily  upon  the  calibre  of  the  aneu- 
rismal  sac,  and  must  be  decided  upon 
with  the  greatest  nicety  of  judgment, 
since  with  too  small  an  amount  little 
or  no  result  will  be  obtained,  and,  with 
too  great  a  quantity,  permanent  cure 
through  obliteration  of  sac  by  contrac- 


Case  of  aortic  and  innominate  aneurism,  with 
erosion  of  the  clavicle  and  ribs.  Photograph 
was  taken  thirty-five  months  after  Dr.  D. 
D.  Stewart  had  caused  an  arrest  of  the 
growth    of    the    aneurism    by    electrolysis. 

tion  of  clot  cannot  be  expected.  For 
a  globular  sac  of  approximately  three 
inches  in  diameter,  three  to  five  feet  are 
sufficient ;  for  a  sac  of  four  to  five  inches, 
eight  to  ten  feet. 

The  anode,  or  positive  pole,  should  in- 
variably be  the  active  electrode.  This 
is  connected  with  the  wire  and  the  nega- 
tive rheophore — a  large  clay  plate,  or  an 
absorbent  cotton  pad  of  equal  dimensions 
made  after  the  method  of  Massey — is 
placed  upon  the  abdomen  or  the  back. 
The  current  is  slowly  brought  into  cir- 
cuit and  its  strength  noted  by  an  accu- 
rate niilliamp6remeter.     The  increase  is 


314 


ANEURISM.     TREATMENT. 


gradual  for  a  few  moments  until  the 
maximum  strength  supposed  to  be  re- 
quired is  reached.  It  is  maintained  at 
this  until  the  approach  of  the  end  of  the 
session,  and  then  gradually  diminished 
to  zerOj  after  which  the  wire  is  sepa- 
rated from  the  battery,  the  needle  care- 
fully withdrawn  by  rotation  and  counter- 
pressure,  and  the  released  external  por- 
tion of  the  wire  gently  pulled  upon  and 
cut  close  to  the  skin,  the  cut  end  being 
then  pushed  beneath  the  surface.  This 
latter  procedure  is  facilitated  by  using 
care  in  the  introduction  of  the  needle  to 
first  draw  the  skin  at  the  site  of  punct- 
ure a  trifle  to  one  side,  in  order  to  pro- 
cure a  somewhat  valve-like  opening. 

Experience  has  shown  that  the  cur- 
rent-strength must  be  rather  high — from 
40  to  80  milliamperes — and  the  sitting 
long — from  three-fourths  of  an  hour  to 
one  and  a  half  hours.  Thus  used,  the 
following  effects  may  be  expected:  The 
mere  introduction  of  coiled,  snarled  wire 
without  the  conjoint  use  of  galvanism, 
if  practiced  judiciously,  is  in  itself  a 
method  of  value,  since  the  presence  of 
wire,  if  engaging  all  parts  of  the  sac, 
acts  both  as  an  impediment  to  the  blood- 
stream and  at  the  same  time  offers  to 
the  eddies  set  up  multiple  surfaces  for 
clot-formation.  Hence  this  method  has 
more  to  commend  it  than  that  by  mere 
galvanopuncture  with  needles.  By  gal- 
vanopuncture,  although  firm  coagula 
are  produced,  they  are  of  such  trifling 
dimensions  and  engage  such  small  areas 
of  sac- wall  that,  without  impeding  in  the 
least  the  blood-current,  their  dissolution 
rather  than  their  accretion  quickly  fol- 
lows. By  the  application  of  a  strong  gal- 
vanic current  through  coils  of  wire  so 
disposed  that  all  areas  of  the  sac  are 
reached,  it  follows  without  exception,  as 
has  been  noted  in  all  recorded  cases,  that 
consolidation  by  virtue  of  clot-formation 
is  promptly  and  invariably  produced. 
The  solidification  is  rapid,  and  is  gen- 
erally manifest  before  the  end  of  the 
electrical  session,  through  changes  ap- 
parent to  the  eye  and  hand,  in  the  pulsa- 
tion and  in  the  degree  of  consistence  of 
the  sac-wall.  These  changes  become 
more  decided  in  the  course  of  a  few  days, 
until,  after  a  time,  in  the  most  favorable 


cases  a  hard  nodule,  with  a  communi- 
cated pulsation  only,  replaces  the  pre- 
vious expansible  tumor.  This  was  the 
history  of  four  of  the  ten  cases  now 
recorded, — that  of  Kerr,  that  of  Rosen- 
stein,  the  second  case  of  author's,  and 
the  case  of  Hershey, — and  partially  so  in 
the  case  of  Barwell,  of  Roosevelt,  and  in 
the  first  of  the  author's,  all  of  which 
latter  cases  were  totally  beyond  the 
slightest  hope  of  cure  at  the  time  of 
treatment,  as  was  also  the  case  of  Abbe. 
D.  D.  Stewart  (Brit.  Med.  Jour.,  Aug. 
14,  '97). 

Treatment  of  abdominal  aortic  aneu- 
risms by  a  preliminary  exploratory 
cceliotomy  and  peritoneal  exclusion  of 
the  sac  followed  later  by  wiring  and 
electrolj'sis.  The  main  difficulty  lies  in 
the  fact  that  a  determination  of  the 
situation  of  the  aneurism,  even  when  a 
cceliotomy  is  performed,  is  very  great. 
The  objections  to  the  method  are  as  fol- 
low: 1.  The  cure  of  the  aneurism  may 
lead  to  tne  death  of  the  patient  by  ob- 
literating the  orifice  of  important  vis- 
ceral arteries;  this  is  most  likely  to  oc- 
cur in  dealing  with  aneurisms  of  the 
upper  or  eoeliac  division  of  the  abdom- 
inal aortic  tract:  i.e.,  in  about  50  per 
cent,  of  the  cases.  2.  Secondary  rupture 
of  the  sac  from  the  strain  put  upon 
weak  portions  of  the  sac  in  multilocular 
aneurisms,  after  partial  coagulation  of 
the  contents  nas  taken  place  (particu- 
larly likely  to  occur  in  subjects  of  gen- 
eral endarteritis  with  atheroma).  3. 
Escape  of  wire  through  a  large  aneu- 
rismal  orifice  into  the  lumen  of  the 
aorta,  with  migration  upward  into  the 
heart,  leading  to  perforation,  traumatic 
endarteritis,  endocarditis,  with  the  for- 
mation of  secondary  thrombi  and  em- 
boli. 4.  Danger  of  perforating  the  sac 
by  stiff  wire  or  by  overcrowding  the  sac 
with  too  much  wire.  5.  Danger  of  ex- 
tension of  clot  from  the  coagulum  in 
the  aneurism  to  the  main  artery,  lead- 
ing to  fatal  blockade  at  the  bifurcation, 
with  gangrene  of  the  lower  extremities. 

6.  Danger  of  rupture  of  sac  from  sudden 
withdrawal  of  abdominal  support  and 
displacement  of  adherent  organs  in  the 
course  of  the  exploratory  laparotomy. 

7.  Danger  of  mistaking  a  fusiform  for  a 


ANEURISM.     TREATMENT. 


315 


sacciform  aneurism.  8.  Danger  from 
emboli  and  thrombi  following  incom- 
plete coagulation  of  the  blood  in  the 
sac  (a  very  rare  and  practically  un- 
known occurrence  in  abdominal  cases). 
9.  Danger  of  shock.  10.  Danger  of  sep- 
sis. Rudolph  Matas  (Amer.  Medicine, 
June  22,  1901). 

Case  of  aneurism  in  which  temporary 
improvement  by  wiring  and  electrolysis 
obtained,  the  patient  dying  later  as  a 
result  of  rupture  of  the  sac.  From  an 
experience  of  eight  operations  of  this 
character  he  concludes  that  electrolysis 
in  properly  selected  cases  of  aneurism 
is  a  valuable  measure  and  prolongs  life. 
The  operation  itself  is  neither  dangerous 
nor  painful.  The  failure  of  permanent 
cure  does  not  depend  so  much  upon  the 
failure  of  the  operation  to  limit  the 
disease  locally  as  to  the  fact  that  the 
adjacent  parts  of  the  blood-vessel  are 
weak,  and,  when  the  bulging  area  is 
solidified  by  the  clot,  these  lateral  areas 
may  later  on  give  way.  Even  in  these 
cases  life  is  prolonged  by  the  closing 
of  the  weakest  area,  and  it  is  not  to 
be  forgotten  that  in  at  least  one  case 
(Stewart's)  life  was  prolonged  three 
years,  death  taking  place  from  an  alco- 
holic debauch.  Hare  (Therap.  Gaz.,  Jan. 
15,  1903). 

Introduction  of  Foreign  Bodies  into  the 
Sac. — Catgut,  silk,  horse-hair,  fine  wire, 
especially,  have  been  introduced  into  the 
sac  to  promote  coagulation,  but  this 
measure  does  not  meet  with  the  approval 
of  the  profession. 

Antyllus's  Operation. — The  oldest  op- 
eration is  that  of  Antyllus  (fourth  cent- 
ury), which  was  at  first  emjiloyed  only 
for  small  traumatic  aneurisms  of  the 
elbow.  It  consisted  in  tying  the  artery 
above  and  below  the  sac,  opening  the 
latter,  and  removing  its  contents.  It  was 
often  attended  by  suppuration,  secondary 
hemorrhage,  and  ankylosis,  owing  to  the 
fact  that  the  artery  was  tied  immediately 
above  and  below  the  sac,  the  artery  being 
itself  diseased  in  these  regions. 

In  1710,  Anel,  believing  that  the  sac 


would  collapse,  tied  the  artery  above  the 
aneurism,  but  the  true  cause  of  success 
in  such  cases  was  not  discovered  until, 
in  1875,  John  Hunter  proved  experi- 
mentally that  aneurism  was  not  due  to 
localized  weakness  in  the  vessel,  but  to 
a  pathological  condition  of  the  arterial 
wall,  extending  beyond  the  sac. 

The  Antyllus  modified  operation  may 
be  exceedingly  difficult,  on  account  of 
branches  springing  from  the  sac,  and 
from  the  artery  above  and  below  the  sac 
being  so  thickened  as  to  make  it  almost 
impossible  to  tie  them.  After  emptying 
the  sac  a  probe  should,  therefore,  be 
passed  into  the  arteries  above  and  below, 
and  the  latter  only  then  tied. 

When  it  is  too  difficult  to  remove  the 
sac  entirely  a  portion  may  be  left  behind. 

Hunter's  Operation.  —  In  the  Anel 
method  the  artery  was  tied  too  near  the 
sac,  where  the  diseased  arterial  wall  did 
not  allow  the  ligatures  to  hold  firmly; 
by  Hunter's  method  the  artery  is  tied  at 
some  distance  above  the  sac,  where  it  is 
healthy.  The  sac  does  not  collapse;  the 
force  of  the  circulation  is  simply  dimin- 
ished, allowing  the  sac  and  its  contents 
to  be  absorbed. 

Slight  oedema  of  the  limb  is  not  a 
contra-indication  for  Hunter's  opera- 
tion, but  the  aneurism  should  be  of 
slow  growth,  of  moderate  size,  and  the 
sac  not  infiamed.  It  should  not  be  per- 
formed in  multiple  aneurism,  except  if 
there  are  only  two,  and  these  can  be 
operated  on  simultaneously. 

This  operation  may  be  followed  by 
return  of  pulsation  in  the  sac,  and  re- 
currence, secondary  liEemorrhage,  in- 
flammation and  suppuration  of  the  sac, 
gangrene,  pyssmia,  and  septicEemia. 

In  performing  Hunter's  operation  it 
is  advisable  to  make  distal  compression 
for  a  few  seconds  before  tightening  the 
ligature,  so  as  to  distend  the  sac,  and  to 


316 


ANEURISM.     TREATMENT. 


ascertain,  by  digital  compression,  that 
the  pulsation  can  be  entirely  arrested. 

A  rise  in  the  temperature  of  the  limb 
is  observed  after  the  operation,  accord- 
ing to  Holmes  and  Ashhurst.  Accord- 
ing to  the  majority  of  writers,  however, 
the  temperature  first  falls,  rising  only 
when  the  collateral  circulation  is  estab- 
lished. 

After  the  operation  two  sets  of  vessels 
are  formed  for  the  collateral  circulation: 
one  around  the  point  tied,  the  other 
around  the  aneurism. 

In  a  very  few  cases  the  sac  will  be  ob- 
literated, but  a  narrow  channel  will  still 
be  left  for  the  passage  of  the  blood.  As 
the  aneurism  itself  has  caused  previous 
dilatation  of  the  neighboring  vessels, 
those  forming  the  collateral  circulation 
around  the  sac  develop  earlier  in  cases 
where  two  sets  develop.  If  the  aneu- 
rism be  tied  near  the  sac,  but  one  set  of 
collateral  vessels  is  formed. 

Secondary  aneurism,  or  pulsation,  maj' 
occur  in  from  a  few  hours  to  several 
months  after  consolidation  and  contrac- 
tion of  an  aneurismal  sac;  but  in  most 
cases  it  forms  about  twenty-four  hoiirs 
after  the  new  sac,  being  generally  slightly 
higher  up  on  the  artery  than  the  old 
sac.  Eecurrent  pulsation  is  due  to  the 
upper  anastomotic  arch  allowing  too 
much  blood  to  ilow  into  the  artery  be- 
tween the  point  of  ligation  and  the  sac. 
Though  in  some  cases  as  distinct  as  be- 
fore the  operation,  it  usually  consists  in 
a  mere  thrill,  without  iruit. 

Pulsation  in  the  sac  may  also  be  caused 
by  too  rapid  collateral  circulation  being 
re-established  above  the  sac. 

Eecurrent  pulsation  is  best  treated  by 
raising  the  limb,  compressing  the  sac 
moderately,  and  using  cold  with  care. 
If  this  is  unsiTccessful,  the  artery  may 
be  tied  lower  down.  But,  if  there  is 
danger  of  sloughing  of  the  sac,  amputa- 


tion should  be  performed  in  axillary  or 
popliteal  aneurism,  and  Antyllus's  modi- 
fied operation  in  cervical  or  inguinal 
aneurism.  The  prognosis  of  cases  of  re- 
current pulsation  is  usually  favorable,  as 
it  will  usually  disappear  when  the  sac 
consolidates.     (Ashhurst.) 

Secondary  haemorrhage  is  most  likely 
to  take  place  from  the  seventh  to  the 
fifteenth  day,  and  on  the  upper  than 
on  the  lower  limb,  owing  to  the  more 
abundant  arterial  anastomosis  on  the 
former.  It  is  favored  by  the  presence 
of  large  branches  given  off  close  to  the 
point  of  ligation.  Strong,  well-prepared, 
chromicized  catgut  is  less  likely  to  be 
followed  by  secondary  hsemorrhage  than 
silk. 

If  after  ligation  the  tumor  enlarges, 
but  without  pulsation,  it  is  due  to  blood 
coming  from  the  artery  beyond  the  sac. 
The  obstruction  of  the  venous  circula- 
tion caused  by  this  may  give  rise  to  gan- 
grene. However,  in  most  cases  the  blood 
coagulates,  and  the  aneurism  forms  a 
solid  fibrinous  tumor. 

Suppuration  and  sloughing  of  the  sac 
after  Hunter's  operation  may  be  due  to 
recurrent  pulsation  from  want  of  con- 
solidation due  to  an  imperfectly  devel- 
oped lower  collateral  circulation,  or  to 
total  sudden  coagulation  of  the  blood  in 
the  sac,  from  complete  arrest  of  the  cir- 
culation, from  violence  or  handling  of 
the  tumor.  Death  results  in  about  35 
per  cent,  of  cases  where  the  sac  Ijursts. 

Hssmorrhage  is  most  common  in  cases 
where  recurrent  pulsation  has  occurred; 
if  suppuration  is  delayed,  no  hemor- 
rhage may  occur,  owing  to  the  arteries 
communicating  with  the  sac  having  be- 
come sufficiently  occluded. 

Gangrene  occurs  usually  from  the  third 
to  the  tenth  day.  It  is  always  moist  gan- 
grene, and  is  most  frequent  in  the  lower 
limb.    In  some  cases  it  may  be  prevented 


ANEURISM.     TREATMENT. 


317 


by  opening  the  sac  and  removing  its  con- 
tents in  order  to  relieve  the  pressure  on 
the  veins.  When  gangrene  is  really  pres- 
ent, the  upper  limb  should  be  removed 
at  the  shoulder-joint,  in  most  cases,  and 
amputation  at  the  junction  of  the  upper 
and  the  middle  thirds  of  the  thigh,  in 
the  lower  limb.     (Ashhurst.) 

Ligation  Below  the  Sac. — Among  the 
methods  best  known  are  Brasdor's,  in 
which  the  artery  is  tied  below  the  sac, 
thus  completely  arresting  the  circula- 
tion, and  Wardrop's  operation,  in  which 
the  artery  or  a  branch  is  tied  below  the 
aneurism,  so  as  to  allow  the  passage  of 
the  blood  throiTgh  another  branch  or 
branches,  thus  only  partially  arresting 
the  circulation.  Brasdor's  operation  is 
used  in  aneurism  of  the  carotid,  external 
iliac,  etc.,  and  Wardrop's  operation  in 
aneurism  of  the  innominate  artery  or  of 
the  arch  of  the  aorta,  where  the  carotid 
or  subclavian  or  both  may  be  tied.  Liga- 
tion below  the  sac  is  considered  as  very 
unreliable.  The  sac  is  likely  to  increase 
in  size,  being  still  subject  to  the  imprdse 
of  the  heart. 

Extirpation  was  first  proposed  in  the 
fourth  century  by  Philagrius,  of  Mace- 
don. 

After  cutting  down  freely  upon  the  an- 
eurism, two  ligatures  are  placed  around 
the  artery  above  the  sac,  and  the  artery 
is  divided  between  them.  The  sac,  with 
its  contents,  is  then  dissected  out,  and  a 
double  ligature  is  applied  to  the  artery 
below  the  sac.  The  vessel  is  divided  be- 
tween these  two  ligatures. 

This  operation  presents  certain  special 
advantages  over  compression,  proximal 
ligation,  or  other  methods,  namely:  the 
permanence  of  the  cure,  the  absence  of 
secondary  haemorrhage,  and  the  absence 
of  danger  of  emboli  or  of  infection. 

Its  mortality,  too,  is  lessened,  having 
been  estimated  by  Delbet  at  11  per  cent., 


whereas  that  of  proximal  ligation  is  18 
per  cent.  Again,  gangrene  occurs  in  but 
3  per  cent,  after  total  extirpation,  against 
about  8  per  cent,  after  proximal  ligation. 
Extirpation  is  indicated  when  the  sac 
has  ruptured,  when  other  methods  have 
been  unsuccessfully  tried,  and,  above  all, 
in  traumatic  aneurisms,  especially  those 
of  the  extremities.  It  is  especially  in- 
dicated in  all  aneurisms  of  the  forearm 
and  leg,  where  the  sac  has  ruptured  and 
caused  sudden  enlargement,  and  where 
rupture  is  impending.  It  is  also  recom- 
mended in  recent  traumatic  aneurisms, 
and  in  arterio-venous  aneurisms  where 
operation  is  indicated. 

Statistics  of  treatment  by  extirpation: 
In  1S8S  the  mortality  was  between  H 
and  12  per  cent.,  but  in  the  76  cases 
since  reported  there  is  not  a  single  death. 
Of  109  cases  treated  by  simple  ligature, 
12  had  gangrene,  while,  of  the  76  cases 
extirpated,  there  were  only  7  instances 
of  this  accident,  and  in  4  of  these  the 
gangrene  existed  before  the  operation. 
Recurrence  is  also  one  of  the  dangers  of 
ligation,  but  it  is  much  less  apt  to  take 
place  with  extirpation — if,  indeed,  it  is 
possible.  Delbet  (La  Semaine  Med.,  Oct. 
30,  '95). 

Results  of  86  cases  treated  by  extir- 
pation. Of  these,  27  were  idiopathic,  59 
traumatic,  29  occurred  in  the  popliteal 
artery,  14  in  the  femoral,  and  the  others 
were  distributed  tolerably  equally  over 
the  remainder  of  the  arterial  system. 
Only  3  deaths  ensued:  1  from  haemor- 
rhage during  the  operation,  1  from  sec- 
ondary hemorrhage,  and  1  after  amputa- 
tion for  gangrene.  Gangrene  occurred  in 
only  2  cases  (2.3  per  cent.),  and  second- 
ary hasmorrhage  in  but  1  (l.I  per  cent.). 
In  contrasting  this  method  with  others, 
it  becomes  evident  that  the  percentage 
of  cases  in  which  gangrene  occurs  is  less 
than  after  ligature  of  the  main  trunk 
above,  while  there  is  here  no  possi- 
bility of  local  relapses.  The  advantages 
claimed  over  the  old-fashioned  method 
of  Antyllus  are  the  following:  1.  The 
length  of  the  after-treatment  is  im- 
mensely diminished,  since  in  many  cases 


318 


ANEURISM.    AORTIC.    SYMPTOMS. 


it  is  possible  to  obtain  primary  union. 
2.  The  risk  of  subsequent  bleeding  is 
greatly  lessened,  since  all  the  collateral 
branches  are  secured,  and  it  was  from 
these  that  it  usuaUy  arose,  and  not  so 
much  from  the  main  trunk.  3.  The 
presence  of  a  thickened  cicatrix,  which 
included  the  doubled-up  and  wrinkled 
sac-wall,  was  likely  to  lead  to  interfer- 
ence with  the  utility  of  the  part,  when, 
as  at  the  knee,  the  aneurism  occurred  in 
the  flexure  of  a  limb.  Kopf stein  (Wiener 
klin.  Rund.,  Nos.  11-16,  '96). 

Advantages  of  the  treatment  of  aneu- 
risms by  excision:  1.  If  the  operation 
can  be  successfully  performed  the  result 
is  a  complete  cure  of  the  aneurism.  2. 
The  ligatures  have  the  advantage  of  be- 
ing applied  to  the  ends  of  the  divided 
vessels,  and  not  to  them  in  their  con- 
tinuity. 3.  Even  if  the  corresponding 
vein  is  divided  and  a  portion  of  it  re- 
moved the  risk  of  gangrene  is  not  great. 
4.  That  in  this  method  all  the  advan- 
tages of  the  antiseptic  treatment  can  be 
obtained,  in  connection  with  the  success- 
ful healing  of  the  wound  and  closure  of 
the  vessels  where  divided.  5.  Inflamma- 
tion and  suppuration  of  the  sac  or  rupt- 
ure of  it  cannot  occur  in  connection  with 
this  method.  6.  Although  as  yet  more 
experience  is  required,  it  seems  likely 
that  certain  aneurisms,  such  as  the  sub- 
clavian, Avill  in  the  future  be  treated 
more  successfully  by  this  method.  T. 
Annandale  (Scottish  Med.  and  Surg. 
Jour.,  Oct.,  1900). 
Aortic  Aneurism. 

Symptoms.  —  Aneurisms  may  be  di- 
vided into  three  groups:  (1)  those  which 
are  entirely  latent,  giving  no  physical 
signs;  (2)  those  giving  signs  of  intra- 
thoracic pressure,  but  in  which  the  na- 
ture of  the  cause  cannot  be  ascertained; 
(3)  aneurisms  which  form  distinct  tu- 
mors and  give  well-marked  pressure 
symptoms  and  external  signs.  (Bram- 
well.) 

Aneurisms  of  the  ascending  portion  of 
the  arch  are  those  most  liable  to  affect 
the  sympathetic.  Eeflex  dilatation  of  the 
pupil  may  thus  be  caused;   the  face  may 


be  pale.  When  the  cilio-spinal  branches 
are  destroyed  the  pi-Lpil  is  contracted; 
the  vessels  of  the  side  of  the  head  may 
be  dilated.  Congestion  and  unilateral 
perspiration  are  also,  though  less  fre- 
quently, observed. 

Tugging  on  the  trachea  is  a  valuable 
symptom,  and  may  be  detected  in  the 
following  manner:  The  patient's  head 
being  inclined  forward  to  relax  the  neck, 
and  the  cricoid  cartilage  being  grasped 
between  the  index  and  the  thumb,  the 
trachea  is  drawn  upward.  If  an  aneu- 
rism is  present  a  well-marked  ascending 
motion  will  be  felt  at  each  pulsation. 

Olivier's  symptom  for  diagnosis  of  aneu- 
rism of  thoracic  aorta,  systolic  pulsation 
of  the  larynx  and  trachea,  is  not  to  be 
expected  in  all  aneurisms  of  the  aortic 
arch,   but  is   especially   to   be   observed, 
either  when  the  aneurism  is  situated  ex- 
actly  at   the   intersection   of   the   aortic 
arch  and  bronchus  or  when,  if  the  aneu- 
rism is  situated  at  the  beginning  of  the 
arch,  it  is  adherent  to  the  anterior  wall 
of  the  trachea.     The   only  other  patho- 
logical condition  which  one  might  expect 
to  produce  similar  symptoms  is  a  tumor 
in  the  anterior  mediastinum.    This  must 
hold  certain  relations  to  the  aortic  arch, 
either  through  pressure  exerted  by  the 
arch,  the   tumor  is  pressed  against  the 
bronchus,  or  it  must  be  adherent  to  the 
convexity  of  the  arch  and  to  the  trachea. 
A.  Fraenkel  (Deutsche  med.  Woeh.,  Jan. 
5,  '99). 
At  times  a  systolic  murmur  is  caused 
in  the  trachea  by  the  air  being  forced 
out  of  it  during  the  systole.    The  sound, 
however,  may  also  be  caused  by  the  sac. 
It  may  be  heard  at  the  patient's  moitth 
when  the  latter  is  well  opened.     Trac- 
tion of  the  tongue  causes  this  symptom 
to  become  more  distinct. 

In  two  oases  a  rhythmical  shake  of  the 
head  observed,  synchronous  with  the  car- 
diac systole  and  due  to  downward  trac- 
tion of  left  bronchial  tube  and  trachea 
by  the  aneurism  at  each  diastole.  Feletti 
(La  Semaine  Med.,  Nov.  6,  '95). 


ANEURISM.    AORTIC.    SYMPTOMS. 


319 


Pain  is  especially  marked  in  deep- 
seated  tumors.  Angina  pectoris  fre- 
quently occurs  in  aneurisms  situated  at 
the  root  of  the  aorta. 

Cough  in  thoracic  aneurism  may  be 
due  to  bronchitis,  or  it  may  be  caused  by 
pressure  on  the  trachea.  The  expectora- 
tion is  at  first  abundant  and  watery; 
later  on  it  is  thick  and  turbid. 

On  percussion  large  aneurisms  pre- 
sent abnormal  dullness.  This  dullness  is 
toward  the  right  when  an  aneurism  of 
the  ascending  arch  is  present,  and  more 
to  the  centre  and  left  in  those  of  the 
transverse  arch.  Aneurisms  of  the  de- 
scending portion  of  the  arch  show  dull- 
ness in  the  left  interscapular  region: 
i.e.,  in  the  space  between  the  spinal 
column  and  the  scapular  border. 

A  ringing,  accentuated,  second  sound, 
heard  over  a  dull  region,  is  frequent  in 
large  aneurisms  of  the  arch. 

Absence  of  pulse  in  the  abdominal 
aorta  and  its  branches  is  observed  in 
cases  of  large  thoracic  aneurism. 

Case  of  aneurism  of  the  aortic  arch 
in  which  the  pulse  of  the  carotids  and 
right  radial  arteries  had  the  reversed 
character  of  the  pulsus  paradoxus. 
There  was  a  very  marked  diminution 
in  the  volume  of  the  pulse  during 
expiration,  and  with  the  respiratory 
variations  there  was  a  definite  ana- 
crotic wave.  Post-mortem  examination 
showed  an  aneui'ism  involving  chiefly 
the  posterior  portion  of  the  aorta  in  the 
region  of  the  transverse  arch.  The  left 
carotid  and  innominate  arteries  sprang 
from  the  anterior  surface  of  the  arch 
instead  of  from  the  convexity,  on  ac- 
count of  the  distension  of  the  aorta. 
With  each  expiratory  excurse  these 
blood-vessels  were  compressed  against 
the  bony  thorax-walls.  J.  Hay  (Lancet, 
Apr.  27,  1901). 

Inspection  is  negative  in  many  cases 
of  aneurism  of  the  aorta,  but  in  some 
abnormal  pulsation  or  a  diffuse  heaving 


impulse  may  be  perceived,  usually  in  the 
first  or  second  right  interspace.  Throb- 
bing may  be  seen  at  the  sternal  notch  or 
in  the  neck  when  the  innominate  artery 
is  involved.  A  tumor  may  be  visible  in 
front  or  in  the  rear,  usually  in  the  left 
scapular  region. 

Dyspnoea  may  be  due  to  compression 
of  the  recurrent  laryngeal  nerves,  of  the 
trachea,  or  of  the  left  bronchus. 

Pressure  on  this  nerve,  especially  on 
the  left  one,  causes  hoarseness  and  loss 
of  voice.  This  may  be  due  either  to 
spasm  or  paralysis  of  the  muscles  of  the 
left  vocal  cord.  Abductor  paralysis  may 
be  the  only  symptom  of  aneurism. 

In  the  early  diagnosis  of  aneurism  of 
the  arch  of  the  aorta,  attention  is  called 
to  the  fact  that  pressure  upon  the  recur- 
rent nerve  from  aneurism  or  thoracic 
tumor  does  not  necessarily  produce 
aphonia.  The  only  subjective  symptom 
of  this  stage  may  be  a  more  or  less  con- 
stant laryngeal  cough.  There  may  also 
be  dyspncea  from  pressure  on  the  bra- 
chial plexus  with  consequent  bron- 
chial spasm.  A  frequent  indication  of 
aneurism  of  the  aorta  is  pain  in  the 
region  of  the  fifth  or  sixth  dorsal  verte- 
bra. Auscultation  of  the  left  interscapu- 
lar space  may  reveal  an  arteriodiastolic 
murmur  not  heard  elsewhere,  or  else  a 
systolic  murmur  due  to  the  beating  of 
the  aneurismal  sac  against  the  left 
bronchus.  Another  auscultatory  phe- 
nomenon is  the  presence  of  the  systolic 
sound  or  thud  in  the  brachial  artery  sim- 
ilar to  that  observed  in  aortic  insuffi- 
ciency. W.  Porter  (N.  Y.  Med.  Jour., 
Dec.  9,  '99). 

Early  diagnosis  of  aortic  aneurism. 
Series  of  54  cases  in  which  38  had  paral- 
ysis of  the  left  recurrent  laryngeal  nerve, 
5  of  the  right  nerve,  and  only  1  of  both 
nerves.  In  all  these  cases  the  patients 
first  consulted  the  author  on  account  of 
hoarseness.  Tracheal  buzzing  was  pres- 
ent in  19  out  of  31  cases.  It  is  best  felt 
when  the  cricoid  cartilage  is  pushed  up- 
ward with  the  index  and  middle  finger 
of  the  right  hand,  the  head  of  the  patient 


320 


ANEURISM.    AORTIC.     SYMPTOMS. 


being  bent  a  little  backward.  A  pulsa- 
tion downward  is  felt  which  ought  not  to 
be  confused  with  the  general  pulsatory 
vibration  of  the  larynx  that  occurs  not 
infrequently  in  excited  patients.  Moritz 
Schmidt  (Med.  Chronicle,  Mar.,  1900). 

Haamorrhage  from  the  air-passages 
may  be  produced  in  three  ways:  (a)  by 
the  formation  of  granulation  tissue  in 
the  trachea  where  it  is  compressed,  in 
which  case  the  bleeding  is  not  abundant; 
(6)  by  the  sac  breaking  into  the  trachea 
or  bronchi;  (c)  by  the  lung-tissue  being 
eroded  or  perforated.  A  patient  may  re- 
cover and  live  for  years  even  after  pro- 


\ 


Aneurism  possibly  arising  from  one  of 
the  pulmonary  sinuses  of  Valsalva. 
[Shoier.) 

fuse  hasmorrhage  occurring  as  the  result 

-of  aneurism. 

A  relatively  frequent  phenomenon  is 
repeated  occurrence  of  hsemoptysis  pre- 
ceding the  opening  of  the  sac  into  the 
bronchial  tubes,  due  to  the  existence 
of  a  small  communication  between  the 
aneurism  and  the  latter.  Hampeln  (Ber- 
liner Idin.  Woeh.,  Dec.  24,  '94). 

Dysphagia  may  be  due  to  spasm  of  the 
oesophagus  or  to  compression.  Perfora- 
tion may  be  induced  by  the  passage  of 
an  oesophageal  bougie.  This  instrument 
therefore  should  not  be  used. 

Ascending  Portion  of  the  Arch. — Aneu- 


risms in  this  region  may  be  situated  just 
above  the  sinuses  of  Valsalva,  or  some- 
what higher,  on  the  convex  border  of 
the  ascending  arch.  In  the  former  case 
they  may  be  small  and  latent,  and  their 
rupture  into  the  pericardium  (usually 
causing  instant  death)  be  the  first  in- 
dication of  their  existence.  "When  this 
does  not  occur  aneurisms  in  this  region 
may  become  exceedingly  large  and  pro- 
ject into  the  right  pleural  cavity  or  for- 
ward, after  destroying  the  sternum  and 
ribs. 

[I  witnessed  and  reported  a  case  in 
\yhich  aneurism  of  the  innominate  artery 
was  suspected  and  in  which  ligation  of 
the  carotid  artery  was  practiced  as  a 
last  resort,  following  the  use  of  iodide 
of  potash,  digitalis,  and  continued  digi- 
tal pressure  for  thirty-six  hours  and 
mechanical  pressure  for  one  hundred 
and  twenty  hours.  The  patient  died 
immediately  upon  the  ligation  of  the 
carotid  artery.  A  post-mortem  exami- 
nation showed  that  the  aneurism  was 
one  involving  the  arch  of  the  aorta  and 
that  coagulation  had  resulted  from  the 
pressure,  but  not  sufficient  to  occlude 
the  vessel.    J.  McFadden  Gaston.] 

Aneurism  probably  arising  from  one 
of  the  pulmonary  sinuses  of  Valsalva. 
Peculiar  features  noted:  Development 
of  the  sac  anterior  and  to  the  left  of 
the  sternum;  the  sac  fills  up  a  large 
portion  of  the  upper  half  of  the  left 
thorax;  absence  of  involvement  of  the 
vagus  and  recurrent  laryngeal  and  of 
the  sympathetic  nerves;  peculiar  and 
unusual  murmurs;  absence  of  irregular 
and  asynchronous  action  of  the  radial 
pulses;    absence  of  tracheal  tugging. 

Points  of  unusual  interest:  1.  Two 
years  since  the  first  symptoms  appeared; 
the  patient  has,  during  the  greater  part 
of  the  time,  been  able  to  be  about  on 
her  feet,  doing  light  work.  2.  Almost 
entire  absence  of  the  usual  pressure 
symptoms.  3.  Remarkable  result  of  the 
therapeutic  measures:  iodide  of  potas- 
sium, mercurial  inunctions,  and  repeated 
venesection.  4.  Decided  benefit  gained 
from  venesection.     On   one   occasion,   at 


ANEURISM.    AORTIC.    SYMPTOMS. 


321 


least,  the  patient's  life  was  undoubtedly 
saved  by  the  prompt  opening  of  a  vein 
and  the  withdrawal  of  twenty-eight 
ounces  of  blood.  J.  B.  Shober  {Amer. 
Jour.  Med.  Sciences,  Feb.,  '97). 

Remarkable  case  of  aneurism  of  one  of 
the  sinuses  of  Valsalva  met  with  in  a 
man,  aged  about  45,  found  dead.  The 
aneurism  bulged  into  the  right  auricle 
and  ruptured  at  a  point  just  above  the 
attachment    of    the    posterior    tricuspid 


In    1840   Thurman   collected   22    cases 
where  aneurism  of  the  aortic  sinuses  was 
present.      Twenty    further    cases    given. 
Cottell    and    Steele    (Inter.    Med.    Mag., 
pp.  258-263,  '97). 
The   situation  of  the  aneurism  with 
reference  to  the  stiperior  vena  cava  and 
subclavian  vein  causes  various  accidents. 
The  aneurism  may  burst  into  the  supe- 
rior vena  cava,  or  may  compress  it,  caus- 
ing engorgement  of  the  vessels  of  the 
head  and  arm;    or  it  may  compress  the 
subclavian  vein,  when  the  right  arm  is 
enlarged. 

Aneurism  of  the  ascending  portion  of 
the  aortic  arch  that  lead  to  external 
rupture.  External  rupture  is  one  of  the 
more  uncommon  terminations  of  a  tho- 
racic aneurism.  According  to  Crisp's 
tables,  this  occurred  six  times  in  one 
hundred  and  thirty-six  cases  of  aneu- 
rism of  the  ascending  arch  which  he 
found  recorded.  Stewart  and  Adami 
(Montreal  Med.  Jour.,  Nov.,  '96). 

Case  of  large  aneurism  of  the  arch  of 
the  aorta  was  treated  by  Macewen's 
method.  The  tumor  occupied  third  right 
intercostal  space  and  was  six  and  one- 
half  centimetres  across  at  its  base.  At 
five  different  times  two  needles  were 
inserted,  and  at  two  other  times  one 
needle.  The  needles  were  removed  one 
or  two  days  later.  The  treatment  re- 
quired about  two  months.  No  swelling 
could  then  be  perceived  at  the  level  of 
the  tumor.  It  was  almost  as  hard  as 
bone;  percussion  gave  dullness  over  the 
manubrium  of  the  sternum  and  extend- 
ing somewhat  to  its  right.  A.  Gignane 
(Gaz.  degli  Osp.  e  d.  Clinic,  No.  62,  '96). 
These  aneurisms  may  affect  the  right 

1 


recurrent  laryngeal  nerve;  and  also  com- 
press the  inferior  vena  cava,  which  is  fol- 
lowed by  ascites  and  oedema  of  the  feet. 
Point  in   aortic   aneurism   emphasized 
of  recent  years:    the  comparatively  fre- 
quent  latency    of    aortic    aneurism,    the 
disease  then  giving  rise  to  very  few  or 
indefinite  symptoms.    A  paralysis  of  the 
left  vocal  cord  may  constitute,  the  first 
means     of     recognizing     the     aneurism. 
Auscultation  of  the  upper   part  of  the 
left  interscapular  space  may   reveal   an 
arterio-diastolic  murmur  not  heard  else- 
where, or  there  may  be  here,  or  in  the 
neighborhood,  a  systolic  murmur  due  to 
the   beating   of  aneurismal    sac   on   the 
left  bronchus.    Gerhardt  (Deutsche  med. 
Woch.,  June  10,  '97). 
The  heart  may  be  pushed  down  to  the 
left. 

Eupture  into  the  pleura  or  superior 
vena  cava  is  the  usual  cause  of  death, 
but  this  may  be  due  to  heart-failure  or 
to  external  rupture. 

Transverse  Arch. — Three  varieties  of 
aneurism  are  observed  in  this  location. 
In  the  first  and  most  common  form  the 
aneurism  is  small  and  not  visible  exter- 
nally. The  growth  is  directed  backward 
or  downward  and  may  involve  the  oesoph- 
agus, causing  dysphagia.  The  trachea 
may  also  be  pressed  upon,  giving  rise  to 
cough,  which  is  often  paroxysmal.  The 
left  recurrent  laryngeal  nerve  may  also 
be  compressed  as  it  passes  around  the 
arch  of  the  aorta  or  a  bronchus.  In  the 
latter  case  bronchiectasis,  bronchorrhoea, 
and  suppuration  into  the  lung,  not  un- 
commonly the  cause  of  death,  may  result. 
The  second  variety  of  aneurism  of  this 
class  is  that  in  which  the  mass  may  pro- 
ject forward  and  simulate  a  large  tumor. 
It  may  destroy  the  sternum  and  pene- 
trate the  opening  thus  created. 

In  the  third  class  the  aneurism  may 
grow  on  both  sides  into  the  pleura  be- 
tween the  sternum  and  vertebral  column. 
This  form  may  last  for  years.     The  ca- 
21 


322 


ANEURISM.    AORTIC.    DIFFERENTIAL  DIAGNOSIS. 


rotid  (radial  pulse)  may  be  affected  by  the 
involvement  by  the  sac  of  the  innom- 
inate artery,  or  more  rarely  the  carotid 
and  subclavian  arteries. 

Compression  of  the  thoracic  duct,  an 
occasional  complication,  may  finally  in- 
duce inanition.  When  the  compression 
includes  the  sympathetic  nerve,  there  is, 
at  first,  dilatation  of  the  pupil;  this  may 
be  followed  by  paralysis,  with  contrac- 
tion of  the  pupil.  Pressure  of  the  ver- 
tebrae may  cause  severe  pain;  of  the 
oesophagus,  dysphagia;  of  the  lungs  or 
bronchi,  bronchiectasis,  the  retention  of 
pulmonary  secretions  giving  rise  to  fever. 

Most  are  saccular;  some  are  small  and 
spring  from  the  aorta  just  above  the 
aortic  ring.  Another  variety  springs 
from  the  anterior  and  upper  aspect  of 
the  aorta  in  the  form  of  large  tumors, 
or  from  the  descending  aorta  and  the 
lower  surface  of  the  arch,  compressing 
the  trachea  or  bronchi. 

In  intrathoracic  aneurism  clubbing  of 
the  fingers  and  incurving  of  the  nails 
of  one  hand  may  also  be  observed,  even 
when  no  venous  engorgement  is  present. 

Sudden  death  may  be  induced  by  rupt- 
ure into  the  pleura  or  a  small  and  latent 
aneurism  bursting  into  the  oesophagus. 
The  spinal  cord  may  be  compressed  and 
give  rise  to  disorders  of  locomotion. 

Differential  Diagnosis. — When  the  an- 
eurism is  in  the  thorax,  the  conditions 
with  which  it  may  be  confounded  are: — 

1.  Violent  throbbing  of  the  arch 
through  marked  aortic  insufficiency. 

2.  Displacement  of  the  heart  through 
the  deformity  caused  by  spinal  curvature. 

3.  Pulsating  pleurisy  can  be  differ- 
entiated by  means  of  a  fine,  hypodermic 
needle.  In  pulsating  pleurisy  the  throb- 
bing is  usually  wide-spread  and  diffuse; 
in  aneurism  there  is  a  firm,  heaving  dis- 
tension and  a  diastolic  shock. 


4.  Tumors.  In  deep  tumors  the  pain 
is  likely  to  be  more  severe.  Pressure 
phenomena  are  most  common  in  aneu- 
rism. When  the  abdominal  aorta  is  in- 
volved, neurotic  pulsation  of  the  latter 
shoi;ld  be  suspected. 

'  Almost  none  of  the  symptoms  are  due 
to  the  aneurism  itself,  but  most  are 
produced  by  the  influence  of  the  tumor 
upon  neighboring  structures.  A  certain 
amount  of  dull  pain  may  be  due  to  the 
distension  of  the  sac-wall  itself;  but  this 
is  usually  entirely  overshadowed  by  that 
produced  by  alterations  in  parts  in  the 
neighborhood.  For  our  diagnosis  we 
must  depend  not  so  much  upon  the 
physical  signs  of  an  arterial  tumor  as 
upon  those  due  to  an  abnormal  growth 
of  whatever  nature. 

The  typical  signs  of  aneurism  may  be 
said  to  be  tumor,  expansile  pulsation, 
thrill,  bruit,  and  shock.  Tumor  is  fre- 
quently absent;  expansile  pulsation  is, 
in  many  situations,  impossible  of  detec- 
tion; thrill  is  a  very  uncertain  signj 
bruit  is  as  often  absent  as  present;  while 
shock,  Avhether  diastolic  or  systolic,  is 
frequently  absent.  F.  A.  Packard  (Mass. 
Med.  Jour.,  Oct.,  '97). 

Radioscopy  is  of  value  in  the  study  of 
aneurisms  of  the  arch  of  the  aorta,  but 
of  little  use  in  case  the  descending  aorta 
is  affected,  as  under  the  latter  conditions 
the  shadow  of  the  heart  overlies  that 
of  the  aneurism.  G.  R.  Murray  (Prac- 
titioner, Feb.,  '98). 

The  fluoroscope  in  diagnosing  anei? 
risms  of  the  aorta.  While  aneurisms 
usually  throw  a  shadow  beside  the  heart, 
which  can  be  seen  to  enlarge  in  all  di- 
rections with  each  heart-beat,  this  must 
not,  however,  be  regarded  as  pathogno- 
monic. Case  in  which,  although  the 
shadow  was  well  defined  and  the  pulsa- 
tion marked,  necropsy  showed  carcinoma 
of  the  cardia  with  extreme  dilatation  of 
the  oesophagus  above,  thus  simulating 
aneurism.  G.  Kirchgaesser  (Munchener 
mcd.  Woch.,  May  8,   1900). 

Case  of  aneurism  of  the  aorta  in 
which  pain  along  the  intercostal  nerves, 
on  both  sides,  with  marked  disturbances 


ANEURISM.     AORTIC.     ETIOLOGY.     TREATMENT. 


323 


of  sensibility, — i.e.,  intercostal  neuritis, 
due  to  pressure, — was  the  main  symp- 
tom of  the  aneurism  for  months.  Sub- 
jective symptoms  were  entirely  absent. 
Frick  (Wiener  klin.  Woch.,  June  20, 
1901). 

The  diagnosis  of  aortic  aneurism  still 
remains,  in  obscure  eases,  a  difficult  one, 
and  even  the  x-ray  examination  may 
be  misleading.  Attention  called  to  the 
frequency  with  which,  in  aneurism  of 
the  arch,  the  left  supraclavicular  groove 
is  obliterated  or  even  bulges,  and  the 
left  external  jugular  is  obviously  fuller 
than  the  right.  The  anatomical  reason 
lies  simply  in  the  compression  of  the 
left  innominate  vein  as  a  result  of  the 
dilated  arch.  A  mediastinal  tumor  may 
have  the  same  effect,  but  dilatation  in 
cases  of  aortic  insufficiency  is  appar- 
ently seldom  sufficient  to  effect  com- 
pression. Dorendorff  (Deutsche  med. 
Woch.,  Nov.  31,  1902). 

Etiology.  —  Aortic  aneurism  is  espe- 
cially due  to  alcohol,  syphilis,  and  over- 
work. Sudden  muscular  exertion  may 
lacerate  the  media.  The  etiological  fac- 
tors of  aneurisms  in  general  may  all  be 
considered  as  capable  of  promoting  aneu- 
rism of  the  aorta. 

Treatment.  —  All  methods  shoiild  be 
aided  by  rest  in  bed  and  proper  diet. 

It  is  unnecessary  to  give  large  doses 
of  potassium  iodide,  viz.:  from  10  to  20 
grains  thrice  daily.  This  drug  relieves 
pain,  causes  thickening  and  contraction 
of  the  sac,  and  lowers  the  blood-press- 
ure. Pain  may  sometimes  be  relieved  by 
anodyne  plasters  or  embrocations,  but 
morphine  may  be  necessary  in  the  final 
stages.  Ice  poultices,  recommended  by 
some  to  relieve  pain,  are  liable  to  cause 
gangrene  of  the  skin,  owing  to  deficient 
circulation.  Chloroform  may  be  used  in 
dyspnoea.  Small,  but  repeated,  venesec- 
tions are  highly  recommended  for  the 
latter  symptom. 

Venesection — removal  of  from  27  to  30 
ounces — followed    by    great    relief   from 


paroxysmal  dyspnoea  and  from  pain, 
lasting  nine  months  in  one  case.  One 
copious  venesection  recommended.  Davi- 
son (Lancet,  May  19,  '94). 

Tracheotomy  may  be  useful  when 
dyspnoea  is  due  to  bilateral  abductor 
paralysis,  but  not  when  it  is  due  to 
compression  at  the  bifurcation,  which 
is  almost  always  the  case. 

Where  external  rupture  of  an  aneu- 
rism is  feared  hemlock  or  lead  plaster 
may  be  used  as  a  support.     (Ashhurst.) 

Laceration  of  the  media  frequently 
occurs  in  the  ascending  portion  of  the 
arch  previous  to  the  occurrence  of  com- 
pensatory thickening.     (Osier.) 

TufEnell's  treatment  of  restricted  diet 
and  rest  in  bed  has  given  satisfactory 
results. 

If  the  milder  methods  do  not  succeed 
needling  should  be  tried,  aided  by  distal 
compression,  when  feasible,  during  the 
use  of  the  needles;  if  this  fail,  distal 
ligation  should  be  resorted  to.  (Nan- 
crede.) 

In  treatment  of  aneurism  of  aortic 
arch  following  conclusions  reached:  I. 
The  remedy  lies  within  the  domain  of 
surgery.  2.  There  are  but  two  such 
methods  at  the  present  time  to  be  con- 
sidered: (o)  obstruction  of  the  right 
subclavian  and  common  carotid  arteries; 
(6)  introduction  of  wire  or  needles  into 
the  sac,  with  or  without  galvanism.  3. 
Either  one  or  both  of  the  operations 
should  be  applied  in  all  cases  after  a 
thorough  saturation  with  the  iodides.  4. 
Ligation  is  attended  by  less  danger,  less 
mortality,  greater  and  more  permanent 
and  universal  benefit.  B.  Merrill  Ricketts 
(Jour.  Amer.  Med.  Assoc,  Aug.  13,  '98). 

Discussion  on  treatment  of  aneurism 
of  the  aorta.  Golubinin,  of  Moscow, 
had  employed  in  8  cases  the  method  of 
treating  aortic  aneurisms  by  injection  of 
gelatinized  serum  recommended  by  Lan- 
eereaux  and  Paulesco.  The  number  of 
injections  varied  according  to  the   case 


324 


ANEURISM.    AORTIC.    TREATMENT. 


from  2  to  15.  Of  the  8  patients,  4  died 
in  a  short  time  and  the  other  4  were  lost 
sight  of;  in  3  of  the  cases  belonging  to 
the  latter  group  the  injections  produced 
no  effect.  In  the  remaining  1  they  were 
followed  by  slight  improvement  in  the 
subjective  symptoms  without  modifica- 
tion of  the  objective  signs.  Golubinin 
had  come  to  the  conclusion  that  the 
method  did  not  fulfill  the  expectations 
that  had  been  founded  on  it.  In  the 
treatment  of  aortic  aneurism.  Huehard 
says  it  is  a  mistake  to  allow  one's  self 
to  be  hypnotized  by  the  changes  to  be 
brought  about  in  the  content  of  the  sac, 
— that  is  to  say,  in  the  blood, — and  to 
take  no  account  of  the  containing 
structure.  The  method  of  gelatinized 
injections,  which  is  useful,  although  in- 
sufficient, is  open  to  this  criticism.  To 
complete  its  action,  especially  in  persons 
with  large  heart  and  increased  arterial 
tension, — they  are  almost  always  at  the 
same  time  subjects  of  Bright's  disease, — 
medicaments  should  be  chosen  which  di- 
minish arterial  tension,  such  as  potas- 
sium iodide,  trinitrin,  nitrite  of  amyl, 
and  especially  tetranitrate  of  erythrol,  or 
tetranitrol,  which  Huehard  has  now  used 
for  a  considerable  time  and  which,  as 
compared  with  trinitrin,  has  the  ad- 
vantage of  a  more  durable  action.  More- 
over, an  essential  point  is  to  supervise 
the  diet  not  in  regard  to  quantity,  as  in 
Valsalva's  method,  but  in  regard  to 
quality.  Meat,  which  holds  too  large  a 
place  in  our  food,  contains  toxins,  which 
have  an  excessively  powerful  vasocon- 
strictor action.  The  best  treatment  of 
aortic  aneurism  is  still  absolute  milk 
diet  regularly  adhered  to.  (Section  of 
Therap.,  Inter.  Congress  of  Med.,  1900; 
Brit.   Med.   Jour.,  Oct.    13,    1900). 

Remark  on  treatment  of  aneurism  of 
the  aorta  by  the  insertion  of  a  perma- 
nent wire  and  galvanism  based  on  a  re- 
port of  5  cases.  A  black  varnish  or 
lacquer  makes  the  best  insulation  for  the 
needle.  The  disposition  of  the  wire  in 
the  lumen  of  the  sac  is  an  important 
factor  in  the  amount  and  the  effective- 
ness of  the  fibrin  whipped  out.  A  small 
quantity  of  wire  possessing  a  good  spring 
should  be  selected.  Cure  of  the  aneurism 
demands  as  complete  contraction  as  pos- 


sible of  the  sac-wall  upon  the  clot  formed 
at  or  soon  after  the  operation.  The  wire 
should  be  of  such  amount  and  material 
as  not  to  interfere  seriously  with  this 
contraction.  The  corrosion  of  the  wire 
by  the  electric  cuiTcnt  makes  a  rough 
surface  very  conducive  to  the  rapid 
whipping  out  of  fibrin.  Within  certain 
limits,  the  wire  most  easily  corroded  is 
to  be  preferred.  The  sac  should  never 
receive  both  poles,  and  the  negative  elec- 
trode should  never  be  in  the  sac.  Sepsis 
is  an  omnipresent  danger.  Another 
danger  is  that  of  the  development  and 
rupture  of  a  secondary  sac  due  to  the 
rapid  filling  up  of  the  main  sac  by  coag- 
ulum,  and  the  shunting  of  the  blood- 
stream against  a  portion  not  receiving  a 
special  strain  before.  Thirty-nine  per 
cent,  of  successful  results  reported  in  the 
23  eases,  including  the  author's  5,  found 
in  literature.  G.  L.  Hunner  (Johns  Hop- 
kins Hosp.  Bull.,  Nov.,  1900). 

In  these  cases  graduated  exercise, 
baths,  and  the  Schott  method,  with  a 
suitable  dietarj',  sometimes  afford  marked 
relief. 

Case  of  aneurism  of  the  aorta  treated 
by  mineral  baths  and  graduated  walking 
exercise,  with  a  liberal  nitrogenous  di- 
etary and  free  ingestion  of  fiuids  to 
eliminate  uric  acid,  etc.  After  six  weeks 
the  patient  could  walk  with  comfort 
during  three  hours  a  day.  A  sciagraph 
showed  that  there  was  no  increase  in 
the  size  of  the  aneurism  in  spite  of  the 
exercise.  Recurrence  of  the  symptoms 
promptly  yielded  to  the  same  treatment. 
Bezly  Thorne  (Brit.  Med.  Jour.,  Mar.  6, 
'97)." 

In  this  form  of  aneurism  favorable 
results  are  sometimes  obtained  by  the 
introduction  of  foreign  bodies. 

Fifteen  cases  of  aortic  aneurism  in 
which,  when  practicable,  introduction  of 
silk-worm  gut  was  resorted  to.  In  one 
case  the  gut-fibres  were  absorbed  after 
the  desired  effect  had  been  produced. 
Von  Schi-otter  (Inter,  klin.  Rund.,  Nov. 
26,  '93). 
In  1895  Dastre  demonstrated  that  the 
injection  of  a  solution  of  gelatin  into  the 


ANEURISM.     CAROTID.     SYMPTOMS. 


335 


veins  of  a  clog  rendered  the  blood  more 
coagulable.  This  discovery  has  recently 
been  utilized  in  the  treatment  of  aneu- 
rism of  the  first  portion  of  the  arch  of 
the  aorta. 

Case  of  a  man,  aged  46  years,  who  had 
a  large  aneurism  undoubtedly  due  to  a 
malarial  aortitis,  which  had  eroded  the 
second,  third,  and  fourth  right  cartilages, 
the  extremities  of  the  corresponding  ribs, 
and  a  large  portion  of  the  sternum.  On 
the  surface  of  the  tumor  there  were 
patches  of  ecchymosis  which  were  soft 
and  depressible,  and  in  the  neighborhood 
of  which  the  blood  was  directly  in  con- 
tact with  the  very  thin  skin.  On  Janu- 
ary 20th  13  drachms  of  a  1-per-cent. 
sterilized  solution  of  gelatin  in  a  0.1-per- 
cent, solution  of  sodium  chloride  was 
injected  into  the  subcutaneous  tissue  of 
the  left  buttock.  The  solution  was  in- 
jected at  a  temperature  of  98.4°  F. 
There  was  a  slight  reaction  following 
this  injection.  During  the  following 
days  the  tumor  became  somewhat  dimin- 
ished in  volume  and  the  pains  completely 
disappeared;  but  soon  the  tumor  re- 
turned to  its  former  dimensions,  the 
walls  again  became  soft,  and  the  inter- 
costal pains  returned.  On  February  10th 
a  second  injection  of  5  ounces  of  a  solu- 
tion similar  to  that  first  employed  was 
given.  This  solution  was  followed  by 
results  similar  to  those  which  followed 
the  first  injection,  except  that  there  was 
no  reaction.  Since  that  time  twelve  in- 
jections similar  to  the  second  have  been 
made  at  intervals  of  from  two  to  five 
days.  The  tumor  diminished  in  volume 
(one  inch  in  the  vertical  and  one-half 
inch  in  the  transverse  diameter).  It  is 
very  firm,  and,  although  on  palpation 
a  pulsation  can  be  felt,  that  pulsation 
is  not  expansile,  but  is  transmitted  from 
the  aorta.  The  pain  entirely  disappeared. 
Laneereaux  (Gaz.  des  Hop.,  June  24, 
'97). 

Case  of  aortic  aneurism  in  which  the 
tumor  extended  over  the  sternum,  the 
sternal  portions  of  the  clavicles,  and  the 
whole  anterior  surface  of  the  neck,  its 
diameter  being  seven  and  one-half  inches. 
Injections  in  the  vicinity  of  the  tumor  of 


75  minims  of  gelatin,  suspended  in  10 
drachms  of  sterilized  normal  saline  solu- 
tion, were  given  every  four  days.  Under 
this  treatment  its  size  has  decreased, 
the  hoarseness  has  disappeared,  and  the 
general  condition  is  improved.  Carl  Beck 
(N.  Y.  Med.  Jour.,  Apr.  15,  '99). 

Gelatin  Injections  in  aortic  aneurism. 
The  first  indication  is  to  eradicate,  if  pos- 
sible, the  cause.  By  increasing  the  co- 
agulability of  the  blood  the  sac  may  now 
be  obliterated.  This  is  most  efficiently 
accomplished  by  gelatin.  Gelatin  injec- 
tions (15  grains  of  gelatin  in  2V3 
drachms  of  sodium-chloride  solution  once 
a  week)  may  then  be  resorted  to.  Re- 
markable results  on  personal  case  in 
which  five  weeks  of  this  treatment  prac- 
ticallj'  freed  the  patient  from  symptoms 
both  subjective  and  objective.  In  this 
case  the  iodides  had  produced  no  eflfect. 
N.  Kalendern  (Klin,  therap.  Woch.,  Jan. 
28,  1900). 

Case  of  very  large  aneurism  of  the 
ascending  aorta,  treated  by  gelatin  and 
electrolysis.  Coagulation  of  most  of  the 
contained  blood  occurred.  The  opera- 
tion was  comparatively  painless  except 
at  the  beginning.  A  few  weeks  later  the 
patient  had  an  attack  of  intermittent 
fever.  Several  large  blebs  formed  near 
the  sternal  margin  of  the  aneurism, 
which  finally  ulcerated  and  revealed  ne- 
crosed fragments.  The  patient  died 
suddenly  from  haemorrhage,  the  blood 
poviring  from  the  point  of  successful 
puncture.  Autopsy  showed  evidences  of 
recent  coagulation.  W.  W.  Johnston 
(Amer.  Medicine,  May  11,  1901). 

Carotid  Aneurism  (in  the  cervical 
region). 

Symptoms. — Aneurism  of  the  carotid 
artery  usually  occurs  where  the  common 
carotid  bifurcates  into  the  internal  and 
external  carotid  arteries.  On  the  right 
side  it  most  frequently  appears  where 
the  artery  springs  from  the  innominate 
artery.  Its  special  symptoms  are  dysp- 
noea, difficulty  in  swallowing,  hoarseness, 
a  brassy  cough,  vertigo,  and  tinnitus 
aurium. 


326 


ANEURISM.     CAROTID.     DIFFERENTIAL  DIAGNOSIS.     TREATMENT. 


Carotid  aneurism  first  appears  as  a 
small  tumor,  which  may  grow  very 
rapidly. 

Case  of  aneurism  of  the  internal  ca- 
rotid following  scarlet  fever  in  a  girl, 
aged  18  years,  severe  inflammation  of 
the  throat  being  a  prominent  symptom. 
A  month  after  the  onset  the  aneurism 
appeared  in  the  left  sterno-mastoid  re- 
gion, immediately  below  the  mastoid. 
It  was  the  size  of  a  walnut,  reducible, 
and  pulsating  energetically.  On  explor- 
atory puncture  with  a  Rravaz  syringe 
blood  was  obtained.  No  treatment  was 
employed.  Gradual  improvement  took 
place,  and  the  patient  spontaneously  re- 
covered in  three  months.  Lyot  and  Retit 
(Revue  des  Sciences  Med.,  July,  '97). 

Case  of  aneurism  of  the  internal  ca- 
rotid artery  following  tonsillar  abscess  in 
a  girl  8  years  old.  The  left  tonsil  and 
the  wall  of  the  pharynx  were  markedly 
protruded;  this,  with  the  enlarged  sub- 
ma.xillai-y  glands,  closely  resembled  post- 
pharyngeal abscess.  The  tumor,  how- 
ever, showed  marked  expansile  pulsation, 
and  aspiration  brought  away  nothing 
but  pure  blood.  During  the  opening  of 
a  tonsillar  abscess  the  carotid  artery  had 
been  wounded,  causing  the  loss  of  a  pint 
or  more  of  blood.  The  child  recovered 
and  an  aneurism  gradually  developed. 
The  common  carotid  was  ligated  just 
below  its  bifurcation.  The  aneurism 
ceased  and  did  not  return.  The  clot  in 
the  sac,  however,  suppurated  and  was 
opened,  and  a  discharge  came  from  the 
left  ear,  which,  however,  finally  disap- 
peared. The  throat  returned  to  its  nor- 
mal size  and  complete  recovery  ensued. 
P.  Wulff  (Miinchener  med.  Woch.,  May 
15,  1900). 

Differential  Diagnosis.  —  At  the  root 
of  the  neck  it  is  sometimes  difficult  to 
ascertain  whether  the  carotid  alone  is 
involved.  Aneurisms  of  the  subclavian, 
the  innominate,  and  the  aortic  arch  may 
simulate  those  of  the  carotid  when  these 
are  close  to  the  clavicles. 

Enlarged  cervical  glands  may  be  taken 
for  aneurism;  but,  as  these  are  iTsually 
multiple  and  not  endowed  with  powers 


of  auto-expansion,  their  diagnosis  is 
easily  established.  Cysts  and  vascular 
growths  of  the  thyroid  resemble  aneu- 
risms in  some  cases.  Cysts  in  the  cer- 
vical region  are  very  rare,  while  any 
growth  connected  with  the  thyroid  gland 
follows  the  movements  of  the  latter  dur- 
ing deglutition. 

Abscess  may  be  taken  for  aneurism, 
especially  cold  abscess,  but  the  cachectic 
facies  is  different,  and  the  growth, 
though  pulsatile  through  the  pressure 
upon  the  underlying  large  vessels,  is 
not  expansile.  An  ordinary  abscess  can 
easily  be  recognized  by  its  characteris- 
tics, which  differ  entirely  from  those  of 
aneurism. 

Prognosis. — Spontaneous  cure  is  rarely 
observed.  The  usual  course  of  an  aneu- 
rism is  to  progress  until  rupture  into  the 
pharynx  or  trachea  or  externally  takes 
place.  Some  cases  remain  dormant  for 
a  long  while,  and  suddenly  undergo  the 
process  of  development. 

Treatment.  —  All  methods  should  be 
supplemented  by  recumbency  and  diet. 
Proximal  compression,  when  feasible, 
should  always  be  tried,  and,  where  the 
arterial  coats  are  seriously  diseased, 
should  supersede  ligation.  Needling 
should  supplement  pressure  when  the 
case  is  progressing  rapidly.  Possibly  it 
is  advisable  in  all  cases  suitable  for  com- 
pression, and  is  certainly  to  be  employed 
where  this  method  fails  in  cases  with 
highly  atheromatous  vessels.  Proximal 
ligation,  having  been  rendered  much 
safer  of  late  by  the  use  of  aseptic  pre- 
cautions, less-absorbent  ligatures,  and 
the  avoidance  of  all  injury  to  the  arte- 
rial walls  by  employing  the  stay-knot,  is 
permissible  when  the  arterial  walls  are 
relatively  sound,  until  experience  decides 
whether  or  not  needling  is  clearly  indi- 
cated. Since  recurrence  after  proximal 
ligation    almost    certainlv    results    from 


ANEURISM.    SUBCLAVIAN.    SYMPTOJIS.     DIAGNOSIS. 


337 


non-deposition  of  white  thrombi  and 
their  maintenance  in  contact  with  the 
aneurismal  wall  from  lack  of  proper 
changes  of  its  lining,  needling  is  clearly 
indicated.  Where  the  location  prevents 
proximal  arrest  of  the  blood-current, 
needling  is  the  best  operation;  possibl}' 
distal  compression  —  rarely  feasible  — 
might  aid  in  the  deposition  of  thrombi. 
For  the  reasons  already  given,  although 
occasionally  successful,  the  indications 
for  the  permanent  introduction  of  such 
foreign  bodies  as  wire,  horse-hair,  etc., 
into  aneurismal  sacs  are  so  much  better 
met  by  needling  that  such  procedures 
had  better  not  be  adopted.  The  modern 
revival  of  the  older  method  of  extir- 
pation of  aneurisms  should  not  be  at- 
tempted for  spontaneous  cervical  aneu- 
risms.    (Nancrede.) 

Extirpation  of  an  aneurism  of  the 
carotid  may,  however,  be  followed  by 
good  resiilts,  even  when  the  common 
carotid  is  involved. 

The  treatment  most  generally  em- 
ployed, if  there  is  room,  i«  to  tie  the 
artery  between  the  sac  and  the  heart, 
and,  if  there  is  not  room  enough,  beyond 
the  sac.  This  may,  however,  be  followed 
by  embolism,  cerebral  softening,  hemi- 
plegia, syncope,  or  by  secondary  hemor- 
rhage or  suppuration. 

More  than  one-third  of  the  deaths 
following  ligation  of  the  common  carotid 
are  due  to  subsequent  cerebral  disease. 

Cerebral  softening  following  ligation 
of  the  common  earotidj  due  to  embolus, 
is  mainly  caused  by  the  arrest  of  the 
blood-current.  Besides  the  trunk  of  the 
common  carotid,  the  internal  carotid 
should  also  be  ligated,  to  prevent  the 
return-current,  which  takes  place  from 
the  internal  to  the  external  carotid. 
Lampiasi  (La  Semaine  Mgd.,  Nov.  11, 
'91). 

Ligation  of  both  common  carotid  ar- 
teries, at  a  year's  interval;  neither  oper- 
ation followed  by  brain  symptoms.    Gay 


(Boston  Med.  and  Surg.  Jour.,  Mar.  8, 
'94). 
When  both  carotid  arteries  must  be 
tied,  it  should  not  be  done  at  the  same 
timej  as  fatal  coma  has  followed  a  simul- 
taneous operation. 

Gentle  handling  of  cervical  aneurisms 
recommended  to  avoid  the  dislodgment 
of  coagula  through  the  internal  carotid. 
Case  in  which  a  rough  manipulation  was 
followed  by  immediate  paralysis.  Hulke 
(Inter.  Med.  Mag.,  Dec,  '92). 

Subclavian  Aneurism. 

Symptoms.  —  Aneurism  of  the  sub- 
clavian attacks  more  especially  the  third 
portion  of  the  artery,  appearing  as  an 


Extirpated  aneuusm  of  the  external 
carotid.      (Delag^niere.) 

(Archives  Provinciales  de  Chirurgie.) 

elongated  tumor  beneath  the  clavicular 
insertion  of  the  sterno-cleido-mastoid. 

The  special  signs  of  subclavian  an- 
eurism are  a  varicose  condition  of  the 
jugular  veins,  a  retarded  pulse  at  the 
wrist,  oedema  of  the  arm  and  hand,  pain 
in  the  nerves  of  the  brachial  plexus,  and, 
if  the  aneurism  is  on  the  right  side,  a 
brassy  cough  from  irritation  of  the  re- 
current laryngeal  nerve.  Two-fifths  of 
the  deaths  following  ligation  of  the  third 
part  of  the  subclavian  are  due  to  intra- 
thoracic inflammation. 

Diagnosis.  —  Aneurism  of  the  sub- 
clavian artery  in  its  third  portion  is  to 


328 


ANEURISM.    AXILLARY. 


be  distinguished  from  carotid  aneurism. 
In  the  former  the  pulse  at  the  wrist  is 
found  delayed  when  compared  to  the 
pulsation  of  the  carotids. 

When  both  the  carotid  and  radial 
pulse  on  the  right  side  are  delayed  as 
compared  to  the  left  carotid  artery,  an- 
eurism of  the  innominate  artery  is  to  be 
suspected. 

Treatment.  —  Medical  treatment  of 
subclavian  aneurism  should  precede  all 
other  methods.  Ligature  of  the  innom- 
inate, when  supplemented  with  simul- 
taneous and  consecutive  ligature  of  the 
associated  contiguous  arteries,  or  by  other 
expedients  equally  well  intended  to  aid 
the  cure,  is  worthy  of  favorable  consid- 
eration.    (J.  D.  Bryant.) 

Pressure  applied  by  the  finger  be- 
tween the  aneurism  and  the  heart,  sup- 
plemented with  general  measures,  has 
been  tried  in  cases  in  which  the  tumor 
was  small.  This  procedure  is  not  easy, 
however,  on  account  of  the  anatomical 
constitution  of  the  region  and  has  been 
replaced  by  direct  pressure  upon  the  sac 
proper. 

When  compression  is  unsuccessful  the 
artery  may  be  tied  beyond  the  aneurism. 
Ligation  between  the  latter  and  the  heart 
has  rarely  succeeded. 

Method  of  controlling  the  circulation 
in  the  upper  extremity  by  elastic  com- 
pression. A  wooden  pad  is  placed  over 
subclavian  and  held  in  place  by  the 
rubber  bandage  of  the  Esmaroh  appara- 
tus; the  bandage  carried  from  the  chest 
over  the  back  and  then  alternately  be- 
tween the  thighs  and  under  the  opposite 
axilla.  W.  W.  Keen  (Med.  and  Surg. 
Reporter,  June  27,  '91). 

Successful  ligation  of  the  first  portion 
of  the  left  subclavian  artery  and  excision 
of  a  large  subclavio-axillary  aneurism, 
probably  the  only  successful  case  of  this 
kind  and  the  first  one  of  complete  extir- 
pation of  a  subclavio-axillary  aneurism. 
Halsted  (.Johns  Hopkins  Hospital  Bulle- 
tin, July,  Aug.,  '92). 


Simultaneous  ligation  of  the  common 
carotid  and  subclavian  arteries  recom- 
mended. The  larger  the  aneurism,  the 
greater  the  development  of  collateral 
circulation.  Guinard  (Bull.  G6n.  de 
Ther.,  Jan.  13,  Feb.  15,  28,  '94). 

Simultaneous  ligation  of  the  right 
common  carotid  and  right  subclavian  or 
axillary  artery  appears  to  be  the  opera- 
tion of  choice.  Statistics  showing  six 
cures  and  twenty-two  improvements  out 
of  fifty-six  cases.  Toivet  (Revue  de3 
Sciences  Medicales  en  France  et  9. 
I'etranger,   Jan.    15,    '94). 

Study  of  one  hundred  and  fifteen  oper- 
ated cases  of  subclavian  aneurisms.  De- 
ductions as  to  treatment:  Strict  asepsis 
the  sheet-anchor.  The  best  plan  is  to 
ligate  the  first  portion  of  the  subclavian 
with  a  double  or,  better,  triple,  non- 
contiguous, absorbable  ligature,  without 
rupturing  the  coats.  When  it  is  decided 
to  ligate  the  subclavian  and  the  common 
carotid  in  one  operation,  it  is  best  to 
first  ligate  the  subclavian.  In  idiopathic 
aneurisms  the  defective  general  condi- 
tion of  the  patient  should  be  borne  in 
mind.  Souchon  (Annals  of  Surg.,  Nov., 
'95). 

Case  of  left  subclavio-axillary  trau- 
matic aneurism;  ligation  of  subclavian 
artery  in  its  second  part;  recovery, 
with  perfect  use  of  arm.  Croly  (Med. 
Press  and  Circ,  Feb.  16,  '98). 

Axillary  Aneurism. 

A  peculiarity  of  this  form  is  its  rapid 
growth.  Being  surrounded  by  lax  tis- 
sues, it  develops  very  quickly  and  is  soon 
of  considerable  size.  The  same  anatom- 
ical feature  causes  the  sac  to  be  easily 
inflamed,  its  location  tending  to  assist 
this  by  the  exposure  to  traumatism,  press- 
ure, etc. 

Pain  is  usually  a  prominent  symptom, 
owing  to  pressure  on  the  nerves  of  the 
brachial  plexus.  (Edema  of  the  forearm 
usually  follows  the  venous  obstruction 
induced  by  pressure  of  the  aneiirism  on 
the  venous  trunks.  The  pulse  at  the 
wrist  is  slower  than  that  of  the  opposite 
side. 


ANEURISM.     BRACHIAL.     ABDOMINAL  AORTA. 


329 


An  axillary  aneurism  may  compress 
the  lung,  causing  dry  pleurisy  or  hyper- 
plastic pneumonia,  or  may  erode  the  ribs. 
It  may  invade  the  shoulder- joint,  inter- 
fere with  the  motion  of  the  arm,  and 
cause  ankylosis. 

Traumatic  axillary  aneurisms  are 
caused  by  a  wound,  an  attempt  to  re- 
duce an  old  dislocation,  etc. 

Etiology.  —  Aneurism  of  the  axillary 
artery  is  sometimes  traumatic.  At  other 
times  it  may  be  due  to  elongation  of  the 
artery  by  too  free  motion  of  the  shoul- 
der-joint, or  to  stretching  during  the  re- 
duction of  an  old  dislocation,  especially 
when  the  vessels  are  atheromatous. 

Case  of  axillary  aneurism  caused  by 
the  pressure  of  a  crutch.  Bardeleben 
(Berliner  klin.  Woch.,  Deo.  16,  '89). 

Case   of  axillary   traumatic    aneurism 
caused  by  the  jamming  of  a  pair  of  scis- 
sors up  into  the  axilla,  making  a  punct- 
ured wound  about  1  inch  in  depth.    The 
aneurism  consolidated  spontaneously  and 
was  almost  entirely  absorbed.     This  re- 
sult was  probably  induced  by  elevation 
of  the  arm,  with  the  patient  in  the  re- 
cumbent position.    Willett  (Practitioner, 
Dec,  '98). 
Prognosis. — Spontaneous  cure  of  these 
aneurisms  is  very  rare.     The  sac,  if  al- 
lowed to  do  so,  rapidly  becomes  larger 
and  ruptures  into  the  surrounding  cell- 
ular  tissue,   the   shoulder-joint,    or   the 
thorax. 

Treatment. — Compression  of  the  third 
portion  of  the  subclavian  may  be  first 
tried,  with  or  without  an  elastic  band- 
age applied  to  the  arm.  Compression 
is  usually  very  painful.  Should  these 
methods  fail,  the  third  portion  of  the 
subclavian  may  be  tied. 

The  most  satisfactory  treatment  in 
general  is  to  ligate  the  subclavian  as  far 
away  as  possible,  dividing  the  scalenus 
anticus.  When  the  incision  involves 
considerable  tissue  the  phrenic  nerve 
should  be  watched  for,  and  pushed  aside 


if  met.  Collateral  branches  of  the  artery 
should  also  be  tied  to  diminish  the  risk 
of  secondary  hemorrhage. 

Cases  of  axillary  aneurism,  with  suc- 
cessful   ligation    of    subclavian    artery. 
Neugebauer  (Centralb.  fiir  Chi.,  Aug.  17, 
■95)  ;   Horwitz  (Ther.  Gaz.,  May  15,  '95) ; 
W.  E.  Waters  (Medical  Record,  May  25, 
'95). 
The  treatment  of  traumatic  aneurism 
should  consist  in  arresting  the  circula- 
tion by  pressure  on  the  third  portion  of 
the  subclavian,  opening  the  sac,  and  re- 
moving its  contents.    The  wound  in  the 
artery   should   then  be  found   and  the 
artery  divided  at  that  point,  both  ex- 
tremities being  tied. 
Brachial. 

Brachial  aneurism  is  usually  traumatic 
in  origin.  Venesection,  carelessly  per- 
formed, occasionally  causes  aneurismal 
varix  or  varicose  aneurism  at  the  bend 
of  the  elbow. 

Aneurism  half  the  size  of  an  orange  in 
the  bend  of  the  elbow,  subsequent  to 
venesection,  cured  by  ligature  of  the 
brachial  artery  in  middle  third.  Gallo 
(Le  Dauphine  Med.,  Mar.,  '94). 

Case  diagnosed  as  a  neuroma  of  me- 
dian ner\'e  found,  on  exposing  swelling, 
to  be  a  cured  traumatic  aneurism  of  the 
brachial  artery.     On   account  of  excru- 
ciating pain  artery  cut  above  and  below 
aneurism  and  sac  dissected  out.     Bland 
Sutton    (Med.  Press  and  Circular,  Sept. 
26,  '94). 
Idiopathic  brachial  aneurism  may  be 
treated   by   Hunter's    method,    by    the 
modified  method  of  Antyllus,  or  by  com- 
pression.    In  either  of  these,  however, 
gangrene  of  the  forearm  is  a  possibility. 
When  this  complication  occurs,  amputa- 
tion becomes  necessary. 
Abdominal  Aorta. 

Symptoms. — Aneurism  of  the  abdom- 
inal aorta  is  uncommon,  as  compared  to 
that  of  the  thoracic  aorta.  It  usually 
occurs  near  the  coeliae  axis,  where  it 
may    form    a   fusiform,    sacculated,    or 


330 


ANEURISM.    ABDOMINAL  AORTA.    DIAGNOSIS.    TREATMENT. 


multiple  tumor;  this  may  project  back- 
ward, and  either  erode  the  vertebrse, 
causing  subsequent  numbness  and  tin- 
gling in  the  legs,  which  may  be  followed 
by  paraplegia,  or  it  may  burst  into  the 
pleura. 

This  form  of  aneurism,  however,  usu- 
ally projects  forward  either  in  the  middle 
line  of  the  abdomen  or  somewhat  to  the 
left.  If  it  is  located  high  up,  and  under 
the  pillar  of  the  diaphragm,  it  may  be 
beyond  the  reach  of  the  hand  in  palpa- 
tion. 

There  usually  are  disorders  of  diges- 
tion, especially  vomiting  and  pain,  the 
latter  frequently  simulating  cardialgia. 
It  may  be  located  either  in  the  back  or 
resemble  girdle  pains,  passing  around  the 
sides  to  the  back. 

Case  of  aneurism  of  the  abdominal 
aorta,  with  symptoms  of  renal  colic. 
Cheadle  (Lancet,  Nov.  20,  '97). 

A  distinct  tumor  is  generally  visible 
in  the  epigastric  region.  Locally,  pulsa- 
tion may  be  detected,  while  a  thrill  may 
frequently  be  observed  when  the  hand  is 
applied  over  it. 

Palpation  usually  reveals  the  presence 
of  a  definite  tumor,  showing  a  strong 
expansile  eifort;  the  pulsations  may  be 
double  in  character  when  the  aneurism 
is  large  and  brought  in  contact  with  the 
pericardium. 

Percussion  may  elicit  a  certain  amount 
of  dullness,  usually  intermingling  with 
the  dullness  of  the  left  lobe  of  the  liver. 

Auscultation  will  usually  reveal  a  sys- 
tolic murmur,  and  at  times  a  very  soft 
diastolic  murmur.  The  former  is  fre- 
quently best  heard  by  auscultating  be- 
hind, near  the  spinal  column. 

Differential  Diagnosis. — A  throbbing 
aorta  is  frequently  mistaken  for  an  an- 
eurism. An  abdominal  aneurism  should 
not  be  declared  present  unless  a  definite 
expansile,  pulsatile,  and  graspable  tumor 


can  be  felt,  notwithstanding  the  presence 
of  a  forcible  pulsation,  a  thrill,  or  a  sys- 
tolic murmur. 

Tumors  of  the  left  lobe  of  the  liver,  of 
the  pancreas,  and  of  the  pylorus  may  all 
be  infiuenced  by  the  movement  of  the 
aorta  and  suggest  aneurism,  but  there  is 
no  expansile  action  in  tumors,  and,  if  the 
patient  be  placed  in  the  knee-elbow  posi- 
tion, the  pulsation  will  usually  not  be 
felt,  owing  to  the  tumor  falling  forward 
by  its  weight  and  thus  being  no  longer 
in  contact  with  the  aorta. 

Prognosis. — The  prognosis  is  unfavor- 
able, although  a  few  cases  of  spontaneous 
recovery  have  been  observed. 

Death  may  be  due  to  compression  of 
the  spinal  cord;  paraplegia  and  its  re- 
sults; to  embolism  of  the  superior  mes- 
enteric artery  followed  by  infarction  of 
the  bowela;  to  the  aneurism  bursting 
into  the  retroperitoneal  tissues,  the  peri- 
toneum, or  the  intestine,  usually  the 
duodenum,  or  into  the  pleura;  or  finally 
to  the  abdominal  aorta  becoming  oblit- 
erated by  clots.     (Osier.) 

Treatment.  • —  The  treatment  of  ab- 
dominal aneurism  is  the  same  as  that 
of  aneurism  of  the  thoracic  aorta. 

Pressure  of  the  aorta  above  the  sac  has 
been  successfully  tried  in  a  case  where 
the  aneurism  was  localized  low  down; 
but  it  should  be  remembered  that  trau- 
matism of  the  sac  has  caused  death  in 
similar  cases.  Should  this  treatment  be 
selected  the  pressure  should  be  continued 
for  many  hours,  under  chloroform. 

Case  of  aneurism  of  the  abdominal 
aorta  causing  death  by  rupture  into  the 
stomach.  Great  danger  of  the  adminis- 
tration of  ergot  in  aneurisms,  greatest 
in  cases  where  the  walls  of  the  sac  were 
more  than  ordinarily  attenuated,  or 
where  the  tendency  to  atheroma  was 
marked.  Ridley-Bailey  (Brit.  Med.  Jour., 
July  11,  '91). 
The  introduction  of  gold  or  silver  wire. 


ANEURISM.     ABDOMINAL  AORTA.     TREATMENT. 


331 


-vvitli  or  without  the  assistance  of  electric- 
ity, have  been  used  witli  success. 

Case  in  which  aneurism  of  abdominal 
aorta  was  exposed  by  a  free  abdominal 
incision,  and  a  hollow,  gold-tipped  needle 
inserted  into  the  sac.  Through  this  was 
passed  eight  and  one-half  feet  of  No.  30 
gold  wire,  which  was  connected  with  the 
positive  pole  of  the  battery ;  a  clay  plate 
placed  under  the  buttocks  was  connected 
with  the  negative  pole.  The  current  was 
gradually  increased  to  70  milliamperes 
during  half  an  hour.  The  pulsation  in 
the  tumor  lessened,  but  the  patient  be 
came  collapsed  and  cyanosed,  reviving, 
however,  later  under  stimulant  treat 
ment.  The  wire  was  left  in  the  sac 
and  the  wound  closed.  Patient  died  six 
months  later  from  some  other  aflfection, 
but  there  was  no  recurrence  of  the  aneu 
rism.  Of  11  other  cases  treated  in  this 
way  by  other  surgeons,  4  resulted  in  ap 
parent  cure  and  6  improved.  W.  H, 
Noble  (Phila.  Med.  Jour.,  June  25,  '98) 
Aneurism  of  the  abdominal  aorta  sue 
cessfully  treated  by  introduction  of  silver 
wire  into  the  sac.  A  trocar  was  intro- 
duced into  the  sac,  and  not  much  blood 
issued.  Five  feet  of  silver  wire  were  in- 
troduced without  difficulty.  The  punct- 
ure was  secured  with  a  silk  ligature. 
There  was  some  vomiting  and  a  good 
deal  of  restlessness  after  the  operation. 
A  month  later  consolidation  was  occur- 
ring. The  after-progress  was  uneventful. 
There  is  at  the  present  time  a  hard  mass 
in  the  middle  line  much  smaller  than 
before  the  operation,  and  the  thrill  and 
bruit  have  disappeared.  Her  health  was 
excellent.  John  Langton  (Treatment, 
May  25,  '99). 

Case  of  ligature  of  the  abdominal 
aorta  just  below  the  diaphragm  in  aneu- 
rism of  the  upper  part  of  that  vessel,  the 
patient  surviving  forty-eight  days.  The 
patient  was  a  laboring  man,  52  years  old, 
probably  with  a  syphilitic  history,  for 
whom  it  was  first  proposed  to  employ 
wiring  and  electrolysis,  should  an  ex- 
ploratory section  show  its  feasibility. 
The  patient,  however,  left  the  hospital, 
only  to  return  five  days  later  with  the 
symptoms  of  a  severe  internal  haemor- 
rhage. An  exploratory  section  revealed 
an  enormous  retroperitoneal  hasmatoma 


communicating  ^^■ith  the  aneurism,  and 
the  incision  was  closed.  Repeated  injec- 
tions of  a  2-per-cent.  solution  of  gelatin 
were  given,  and,  the  patient's  condition 
improving,  a  second  operation  was  per- 
formed thirteen  days  later.  The  omen- 
tum was  torn  through,  and  with  a  long- 
handled  pedicle  needle  four  strands  of 
floss  silk  were  carried  from  left  to  right 
under  the  aorta  and  near  the  diaphragm. 
The  silk  was  disengaged  from  the  eye 
of  the  needle  with  great  difficulty  and- 
was  tied.  Immediately  the  head,  face, 
and  neck  became  livid,  but  this  lividity 
subsided  after  a  few  hours.  The  aneu- 
rism shi-unk  to  one-half  its  original  size 
within  a  few  minutes.  Seven  days  later 
the  femorals  were  found  to  be  pulsating 
slightly,  and  the  legs  had  regained  their 
warmth.  The  amount  of  uri-  e  excreted 
after  the  operation  gradually  reached 
the  usual  pre-operative  amount.  Forty- 
eight  days  after  the  operation  the  patient 
died  suddenly  from  haemorrhage  due  to 
ulceration  of  the  aorta  at  the  seat  of 
ligation.  Personal  opinion  that  this  re- 
sult will  almost  certainly  follow  in  any 
case  of  ligation  of  the  aorta  in  which 
death  does  not  result  from  other  causes, 
and  a  removable  clamp  (devised  by  the 
author)  to  be  placed  upon  the  aorta 
through  an  abdominal  incision  and  capa- 
ble of  being  loosened,  tightened,  or  re- 
moved, at  will,  becomes  necessary.  Keen 
(Amer.  Jour,  of  Med.  Sciences,  Sept., 
1900). 

The  case  of  an  abdominal  aortic  aneu- 
rism in  a  woman  noted.  There  was  a 
systolic  "bruit"  over  the  area,  but  the 
heart  was  normal.  Gelatin  was  given 
per  mouth.  Twenty  grammes  dissolved 
in  normal  saline  were  given  daily.  The 
recumbent  position  was  maintained  and 
ice-bags  continuously  applied  to  the  ab- 
domen. Two  months  afterward  the 
tumor  was  less  resistant  and  smaller. 
The  ice-bag  was  then  used  during  two 
hours  daily,  and  the  gelatin  given  every 
other  day.  Four  weeks  later  the  aneu- 
rism could  only  be  felt  as  a  slight  thick- 
ening. The  ice  applications  were  now 
suspended,  and  a  solution  of  ichthyol  in 
CHCI3  and  camphor  spirit  was  rubbed 
over  the  painful  places.  The  gelatin  was 
continued  for  four  weeks,  and  the  patient 


333 


ANEURISM.     ILIAC.     SYMPTOMS.     DIAGNOSIS.     TREATMENT. 


allowed  to  gradually  resume  ordinary 
duties.  Buchholz  (Norsk  Mag.  f.  Laege- 
vidensk.,  p.  185,  1900). 

Iliac  Aneurism. 

An  aneurism  may  form  on  either  the 
common,  internal,  or  external  iliac  arter- 
ies or  one  of  their  branches,  and  be,  as 
in  other  regions,  idiopathic  or  traumatic. 
In  the  latter  case,  however,  the  external 
iliac  is  almost  always  the  portion  in- 
volved. 

Symptoms. — The  enlargement  appears 
as  a  circumscribed  swelling  in  the  line  of 
the  vessel,  presenting  the  characteristic 
expansive  pulsation  and  bruit  along  its 
course.  If  the  genito-crural  is  pressed 
upon,  pain  may  be  a  prominent  feature 
of  the  ease.  Owing  to  the  ease  with 
which  the  surrounding  organs  may  grad- 
ually be  displaced,  however,  the  aneu- 
rism attains  a  large  size  before  it  is  dis- 
covered. (Edema  and  gangrene  some- 
times result  from  the  pressure  induced 
on  venous  trunks.  If  left  to  itself  an 
iliac  aneurism  usually  ruptures. 

Differential  Diagnosis. — Enlarged 
glands  near  Poupart's  ligament  may  sim- 
ulate an  iliac  aneurism.  The  glands  are 
not  pulsatile  and  cannot  be  emptied  by 
pressure,  while  no  bruit  can  be  detected. 
Tumors  and  abscesses  may  be  differen- 
tiated in  the  same  way. 

Treatment. — Aneurism  of  the  common 
iliac  artery  is  best  treated  by  compression 
above  the  aneurism,  as  little  as  possible 
over  the  sac.  A  mortality  of  almost  75 
per  cent,  is  found  as  a  result  of  ligation 
of  the  common  iliac  for  aneurism. 

If  the  aneurism  be  one  of  the  internal 
iliac  and  idiopathic,  pressure  may  be  ap- 
plied above  it,  and,  in  non-success,  co- 
agulating injections,  or  even  ligation  by 
a  median  laparotomy  may  be  resorted  to. 
If  the  aneurism  is  traumatic,  the  artery 
should  be   compressed  above  the  aneu- 


rism, the  sac  incised,  and  the  artery  tied 
above  and  below  the  wound. 

When  dealing  with  the  external  iliac 
artery  and  the  aneurism  is  idiopathic, 
compression  should  be  first  tried,  fol- 
lowed in  case  of  failure  by  ligation  above 
the  sac.  This  operation  may  be  per- 
formed by  a  median  laparotomy.  The 
modified  operation  of  Antyllus  should  be 
used  if  the  aneurism  is  traumatic. 

Case  of  successful  extirpation  of  an 
aneurism  of  the  right  external  iliac  ar- 
tei-y,  occupying  whole  right  iliac  fossa 
and  as  large  as  the  head  of  a  child  at 
term.  Recovery  uneventful,  and  patient 
following  his  occupation  as  a  clown. 
Qu6nu   (Le  Bull.  Med.,  Dec,   '94). 

Case  of  large  ilio-femoral  aneurism. 
Ligation  of  external  iliac  artery.  Pa- 
tient up  by  the  forty-seventh  day.  Three 
months  later  aneurism  in  opposite  groin. 
Operation  repeated:  recovery  much  more 
rapid  than  on  first  occasion,  collateral 
circulation  being  established  more 
promptly.  Patient  a  carpenter.  Makins 
(Brit.  Med.  Jour.,  Nov.  30,  '95). 

Case  in  which  transperitoneal  ligation 
of  the  external  iliac  artery  for  femoral 
aneurism  was  performed  with  subse- 
quent dissection  of  the  sac.  Recovery, 
but  with  complete  paralysis  of  sensation 
over  the  anterior  aspect  of  the  thigh  and 
inability  to  extend  the  leg  on  the  thigh, 
probably  due  to  section  of  some  branches 
of  the  anterior  spinal  nerve  while  laying 
the  sac  open.  N.  P.  Dandridge  (Med. 
News,  Apr.  3,  '97). 

Two  cases  of  ligature  of  the  external 
iliac  artery  for  aneurism  by  the  trans- 
peritoneal method.  The  transperitoneal 
operation  has  many  advantages  over  the 
older  operation,  provided  strict  cleanli- 
ness is  maintained.  In  both  cases  the 
ordinary  operation  would  have  been  diffi- 
cult, if  not  Impossible,  owing  to  the 
position  of  the  swelling.  W.  H.  Brown 
(Lancet,  Oct.  23,  '97). 

The  following  conclusions  offered  as 
fundamental  rules  to  be  observed  in 
the  treatment  of  ilio-femoral  aneurism: 
Whenever  possible,  compression  should 
be  given   a   trial   before   resort  to   more 


ANEURISM.     FEilOEAL.     SYMPTOMS.     DIFFERENTIAL  DIAGNOSIS. 


333 


severe  measure.  If  compression  fails, 
operative  procedures  are  then  indicated, 
and,  when  feasible,  total  extirpation  of 
the  sac  should  be  chosen  as  the  surest. 
These  rules  are  especially  applicable  to 
ilio-fenioral  aneurism,  but  they  are 
equally  so  to  aneurisms  of  other  portions 
of  the  body,  if  they  are  so  situated  as 
to  allow  of  operative  treatment.  F. 
Schops  (Wiener  klin.  Woch.,  Nov.  24, 
'98). 

Case  of  aneurism  of  uterine  artery 
cured  by  ligation  of  internal  iliac  artery. 
Patient  was  originally  operated  on  for  a 
pelvic  abscess,  which  was  opened  through 
the  vagina.  The  incision  was  followed 
by  copious  venous  haemorrhage.  On  ex- 
amination there  was  found  "a  softly 
elastic,  strongly  pulsating,  and  thrilling 
tumor  of  about  the  size  of  a  hen's  egg, 
projecting  into  the  left  vaginal  vault, 
close  to  the  cervix  and  extending  slightly 
down  on  the  left  vaginal  wall."  An  in- 
cision was  made  in  the  left  semilunar 
line  and  the  internal  iliac  artery  was 
isolated  and  tied.  Pulsation,  all  but  a 
slight  transmitted  movement,  entirely 
stopped  in  aneurism  and  the  patient 
made  a  good  recovery.  In  order  to 
doubly  insure  a  cure  galvanopuncture 
was  practiced  twice,  with  noticeable 
benefit.  Paul  F.  Mundg  (Med.  Rec,  Dee. 
31,  '98). 
Femoral  Aneurism. 

Symptoms. — The  femoral  artery  is  fre- 
quently the  seat  of  traumatic  aneurism 
on  account  of  its  exposed  position.  It 
may  involve  the  common,  the  superficial, 
or  the  deep.  It  is  generally  sacculated. 
In  some  cases  it  is  fusiform  or  flattened, 
as  in  Hunter's  canal. 

Differential  Diagnosis. — The  difficulty 
here  lies  in  recognizing  whether  the  dila- 
tation is  on  the  superficial  or  the  deep 
branch,  the  other  characters  peculiar  to 
an  aneurism  being  easily  determined. 
The  sriperficial  branch  is  that  most  fre- 
quently affected,  and  the  arterial  pulsa- 
tions below  are  more  affected  by  it  than 
by  an  aneurism  of  the  superficial  branch. 
The  bruit  of  aneurism  in  cases  where  the 


femoral  or  popliteal  artery  is  the  seat  of 
the  lesion  may  frequently  be  made  more 
distinct  by  placing  the  patient  in  the  re- 
cumbent position  and  elevating  the  limb. 


Case  of  multiple  aneurism.  Vo.  1,  "In- 
guinal" aneurism;  No.  2,  Femoral 
aneurism;  No.  Z,  Small  aneurism, 
which  had  not  been  discovered  during 
the  patient's  life;  No.  4,  Popliteal  an- 
eurism, which  ruptured;  A,  Orifice 
of  femoral  artery;  B,  Inferior  orifice 
of  same;  C,  Continuation  of  poplit- 
eal;   E,  Aneurismal  sae.     (Monro.) 

Case  of  double  aneurism  of  left  thigh: 
one,  the  size  of  an  egg,  at  Scarpa's  tri- 
angle; the  other,  as  large  as  a  cocoa-nut, 
at    the    opening   through    the    abductor 


334 


ANEURISM.    FEMORAL.    TREATMENT. 


■  magnus.  Superficial  femoral  ligated  in 
middle  of  Scarpa's  triangle,  suppuration 
and  two  secondary  haemorrhages  ensu- 
ing; wound  enlarged  and  bleeding  ends 
tied.  Only  one  case  on  record  of  cure  of 
double  aneurism  of  superficial  femoral 
artery  by  operative  procedure.  Souchon 
(N.  Y.  Med.  Jour.,  Nov.  2,  '95). 

Treatment, — In  idiopathic  aneurism  of 
this  artery  digital  or  instrumental  com- 
pression above  the  sac  is  to  be  preferred. 
If  this  proves  unsuccessful,  ligation  is  to 
be  resorted  to.  If  the  aneurism  is  in 
Hunter's  canal,  the  artery  should  be  li- 
gated above;  if  it  is  in  Scarpa's  triangle, 
ligation  of  the  common  femoral  gives  the 
best  results,  although  ligation  of  the  ex- 
ternal iliac  is  usually  preferred,  owing  to 
the  absence  of  branches  where  the  liga- 
ture is  usually  applied. 

The  favorable  statistics  of  the  last 
decade  may  be  greatly  increased  by 
adoption  of  this  method  of  suture:  an 
obliteration  of  the  sac,  instead  of  the 
classical  ligation  of  the  arteries,  with 
or  without  extirpation;  the  closure  of 
the  arterial  orifice,  supplying  the  sac, 
whether  single  or  multiple,  by  sutures; 
and  within  the  sac  simplified  technique 
of  the  other  operation.  A  favorable 
case — namely:  saccular  aneurism,  with 
one  orifice  into  the  trunk  is  best.  It 
is  possible,  by  these  sutures,  to  close 
the  limien  without  narrowing  the  main 
channel.  In  fusiform,  traumatic  aneu- 
risms, and  in  all  with  a  healthy,  friable 
sac,  lost  continuity  of  the  arteries  may 
be  renewed  by  building  a  new  channel 
and  connecting  the  main  orifices  of 
communication.  The  fear  that  atheroma 
and  degeneration  will  interfere  with 
healing  has  been  exaggerated,  especially 
since  it  has  been  shown  that  amputa- 
tions in  aged  patients  with  sclerosed 
arteries  may  well  succeed.  The  failure 
and  danger  of  the  old  operation  of 
Antyllus  lie  in  the  fact  that  ligation 
of  the  main  artery,  above  and  below 
the  sac,  will  not  always  control  the 
bleeding  from  collateral  vessels  opening 
into  the  aneurism,  or  into  the  main 
trunk  between  the  arteries  of  the  sac 
and  the  seat  of  ligation.     The  cutting 


of  the  sac  away  has  the  danger  of  in- 
terfering    with     collateral     circulation. 
The    operation    of    Antyllus,    moreover, 
leaves    the    sac    as    an    open    cavity    in 
the  bottom  of  the  wound,  which  heals 
by   granulation,   and   induces   infection, 
suppuration,     and     secondary     haemor- 
rhage.     All    these    difliculties    are    in- 
creased by   the   extirpation.     R.   Matas 
(Annals  of  Surgery,  Feb.,  1903). 
In  traumatic  aneurism  of  the  femoral 
the  artery  should  be  compressed  on  the 
edge  of  the  pelvis  by  means  of  a  tourni- 
quet, the  sac  opened,  and  both  ends  of 
the  divided  artery  tied. 

Aneurism  in  Scarpa's  triangle,  in  which 
instrumental  compression  above  was  em- 
ployed for  eighteen  days,  but  had  to  be 
abandoned  on  account  of  the  irritation 
of  the  skin  which  it  caused.  The  aneu- 
rism gradually  diminished  in  size  and 
recovery  followed.  MoUoy  (Med.  and 
Surg.  Reporter,  Apr.  22,  '93) . 

Case  of  extirpation  of  a  femoral  aneu- 
rism, in  a  little  girl  of  11,  extending 
from  near  Poupart's  ligament  to  the 
lower  part  of  Hunter's  canal;  it  had 
been  growing  for  fifteen  months,  and 
was  not  attributable  to  injury.  The 
main  trunk  was  first  secured  above  the 
sac,  and  the  whole  mass  enucleated; 
thirty-five  dilated  arterial  twigs  required 
ligature,  and  about  five  and  a  half  inches 
of  the  femoral  vein  were  also  removed. 
The  patient  made  a  good  recovery. 
Heurtaux  (Bull,  et  Mem.  de  la  Soc.  de 
Chir.,  Nos.  9,  10,  '95). 

Two  cases  of  femoral  aneurism 
treated  by  excision.  The  vessel  is  li- 
gated at  its  end  instead  of  in  its  con- 
tinuity and  by  removal  of  the  sac.  Pro- 
vision is  made  against  relapse  through 
diseased  or  injured  vessel,  while  the 
presence  of  more  branches  for  recurrent 
circulation  is  insured.  The  first  case 
was  still  well  three  years  after  the  last 
operation.  The  second  case  died  the 
second  day  from  pulmonary  congestion 
and  oedema.  G.  R.  Fowler  (Med.  Record, 
Mar.  23,  1901). 

Popliteal  Aneurism. 

The  popliteal  artery  being  peculiarly 
liable  to  atheroma,  it  is  the  most  com- 


ANEURISM.    POPLITEAL.    SYMPTOMS.    DIAGNOSIS.    PROGNOSIS. 


335 


mon  seat  of  aneurism  after  the  aorta. 
Flexion  and  extension  of  the  knee,  if 
exaggerated  but  slightly  when  the  vessel 
is  diseased,  act  as  exciting  causes.  The 
aneurism  sometimes  develops  in  this  re- 
gion without  any  apparent  mechanical 
cause,  and  may  present  itself  on  either 
side.  It  usually  grows  posteriorly,  rap- 
idly penetrating  the  surrounding  alveolar 
tissue  and  assuming  large  proportions. 
At  other  times  it  forms  anteriorly,  and 
presses  against  the  bone  or  the  posterior 
ligaments.  Supported  by  these  hard  sur- 
faces its  growth  is  much  slower. 

Case  of  diflfuse  popliteal  aneurism 
caused  by  an  exostosis  due  to  ossifiea- 
tion  of  the  tendon  of  the  adductor  mag- 
nus  muscle.  Similar  case  reported  by 
Boling  quoted  in  which  rupture  of  the 
artery  was  caused  by  two  epiphyseal 
exostoses.  Terrier  and  Hartmann  (Lon- 
don Lancet,  May  20,  '93). 

Symptoms.  —  Although  a  sudden  pain 
may  reveal  the  presence  of  the  aneurism, 
rheumatism  of  the  knee  is  the  usual 
complaint  at  the  start.  The  joint  then 
becomes  weak  and  stiff,  and  examination 
finally  reveals  a  growing  tumor,  pre- 
senting all  the  characteristics  already  de- 
scribed: expansive  pulsations  and  bruit 
extending  down  the  leg.  The  aneurismal 
tumor  can  usually  be  emptied,  but  in 
some  cases  all  the  subjective  symptoms 
have  to  be  very  carefully  sought  after  to 
be  discovered.  The  tibial  pulses  usually 
show  a  marked  difference.  Complica- 
tions frequently  followed  popliteal  aneu- 
rism. Posteriorly,  it  may  compress  the 
veins  and  cause  oedema,  or  give  rise  to 
severe  neuralgia  by  pressing  on  the  pop- 
liteal nerve  anteriorly;  synovitis  may  be 
induced,  causing  severe  pain. 

Case  of  pulsating  tumor  of  the  pop- 
liteal space  simulating  aneurism;  illus- 
trates   importance    of    using    exploring- 


needle  in  deep-seated  fluctuating  tumors. 
Marmaduke  Shield  (London  Lancet,  Oct. 
6,  '94). 

Case  of  popliteal  aneurism  showing,  as 
only   symptom,   cramp-like   pain    in   the 
leg.    J.  Hutchinson,  Jr.   (Med.  Press  and 
Circ,  Oct.  16,  '95). 
Differential  Diagnosis. — Arterial  hsem- 
atoma  presents  the  characteristics  of  pop- 
liteal aneurism  even  when  no  trauma  is 
found.     The  bruit  may  be  present,  but 
the  pulsation  along  the  course  of  the 
vessel  is  weaker.    Osteosarcoma,  glandu- 
lar enlargements,  abscess,  cysts,  may  also- 
simulate  a  popliteal  aneurism,  but  the- 
expansile  nature  of  the  latter,  and  the 
possibility  of  emptying  the  sac,  make  it 
impossible  to  readily  establish  the  nature- 
of  the  case. 

When  the   femoral  artery   above  does, 
not  feel  rigid,  the  aneurism  is  not  due  to. 
atheroma  and  there  is  no  atheromatous^ 
degeneration  in  the  vicinity  of  the  sac. 
Billroth    (Wiener    klin.    Woch.,  No.    50, 
'93). 
Prognosis. — Popliteal  aneurisms  occa- 
sionally undergo  spontaneous  cure.  Usu- 
ally, however,  it  progresses  more  or  less- 
rapidly  according  to  its  location;   begins 
to  leak;    and  finally  ruptures  into  the 
surrounding  cellular  tissue,  the  blood  ex- 
tending along  the  tissues  of  the  leg.    The- 
popliteal  space  becomes  at  once  greatly 
distended.    Considerable  pain  and  faint- 
ness  are  experienced.     The  typical  local 
symptoms   do   not   cease,   however,   al- 
though considerably  reduced  in  intensity. 
The  limb  below  becomes  livid  and  cold,, 
and  gangrene  soon  follows,  if  an  inflam- 
matory process  does  not  come  on.    In  the- 
latter  there  is  redness  of  the  skin,  local 
cedema,  and  severe  pain.     Suppuration 
of  the  joint  is  then  probable. 

[Two  cases  of  this  kind  witnessed  by 
me  were  cured  by  means  of  the  iodide  of' 
potassium  and  compression.  Both  pa- 
tients are  now  strong  and  healthy.  J.. 
McFadden  Gaston.] 


336 


ANEURISM.    TRAUMATIC. 


Treatment.  —  If  there  is  evidence  of 
atheroma  digital  corapression  should  be 
preferred,  provided  there  is  no  fear  of 
impending  rupture.  Esmarch's  bandage 
may  also  be  employed.  Flexion  is  useful 
if  the  aneurism  is  small.  If  these  fail, 
ligation  of  the  femoral  artery  at  the 
apex  of  Scarpa's  triangle  gives  the  best 
results.  The  limb  should  be  carefully 
wrapped  in  cotton  wadding  and  raised 
somewhat.  This  is  especially  indicated 
when  the  sac  is  large,  if  it  is  inflamed, 
when  leaking  has  begun,  or  when, 
through  pressure  on  the  popliteal  vein, 
there  is  oedema  of  the  foot. 

Amputation  is  indicated  when  gan- 
grene follows  ligature,  when  the  sac  has 
ruptured,  or  if  there  is  caries  of  the 
osseous  tissues  or  suppuration  around 
the  sac. 

Case  in  which  total  extirpation  of  the 
sac  was  followed  by  speedy  recovery. 
Statistics  of  forty  eases  confirming  this 
opinion,  twenty-eight  being  cases  of 
arterial  aneurism  and  twelve  arterio- 
venous. Kubler  (Beitrilge  zur  klin.  Chi., 
B.  9,  H.  1,  '92). 

Case  of  bilateral  popliteal  aneurism; 
sacs  extirpated  in  two  sittings  with  com- 
plete success.  Ten  cases  of  this  affection 
reported,  with  nine  recoveries  and  one 
death  from  sepsis.  Schmidt  (Archiv  f. 
klin.  Chi.,  vol.  xliv,  p.  809). 

Popliteal  aneurisms,  if  not  too  large, 
permit  of  the  radical  operation.  The 
portion  of  the  artery  within  the  aneu- 
rism al  sac  is  denuded  and  its  walls  are 
softened.  Secondary  hfemorrhage  is 
likely  to  follow  ligation  at  this  point. 
The  ligature  should  be  applied  outside 
of  the  sac  or  at  a  distance  from  the  open- 
ing in  the  wall  of  the  artery  into  the  sac. 
Primary  union  of  the  walls  of  the  sac 
is  not  to  be  expected.  The  inner  portion 
of  the  sac  becomes  detached  by  necrosis. 
Extirpation  of  the  wall  of  the  sac  is  not 
necessary.  The  wound  should  not  be 
entirely  closed  by  sutures:  the  cavity 
should  be  loosely  packed  with  iodoform 
gauze.  In  the  after-treatment  iodoform- 
and-glycerin    emulsion    is    recommended. 


The  cavity  heals  without  trouble.     Bill- 
roth  (Wiener  klin.  Woch.,  No.  50,  '93). 

Three  cases  successfully  treated  by 
ligation  of  the  femoral  artery  after  com- 
pression and  flexion  had  been  tried  with- 
out success.  Leutaigne  (Dublin  Jour,  of 
Med.  Sci.,  July,  '94). 

Case  of  double  popliteal  aneurism 
treated  by  compression;  three  months 
later  both  sacs  consolidated.  Iodide  of 
potassium,  administered  from  the  start, 
still  continued.  Golding-Bird  (Brit.  Med. 
Jour.,  Jan.   12,  '95). 

Case  of  popliteal  aneurism  cured  by 
forced  flexion  of  the  knee.  Treatment 
begun  by  half-flexion,  which  is  much  less 
painful.  Alessandro  (Riforma  Medica,  p. 
5,  '95). 

Hypodermic  injections  of  ergotin  in 
aneurism  recommended,  the  following 
mixture  being  employed:  — 

IJ  Ergotin  (Bonjean),  40  grains. 

Spiritus  vini  rectificati,  80  minims. 
Glycerini,  80  minims. 

M.  et  ft.  sol.  Inject  3  centigrammes 
under  the  skin  over  the  tumor.  Lang- 
enbeck  (Phila.  Med.  Jour.,  Feb.  14, 1903). 

Traumatic  Aneurism. 

Traumatic  aneurism  is  not  due,  like 
other  aneurisms,  to  an  anterior  patho- 
logical condition  of  the  artery-wall,  but 
to  a  direct  injury  to  the  vessel,  resulting 
in  an  arterial  hsematoma. 

Traumatic  aneurism  may  be  caused  by 
a  shot  or  stab  wound  of  an  artery,  by 
which  the  blood  is  extravasated  into 
the  neighboring  cellular  tissue,  until  it 
is  arrested.  There  are  three  varieties  of 
traumatic  aneurism.  The  true  traumatic 
aneurism  is  the  form  in  which  the  artery, 
generally  a  large  one,  has  received  a 
punctured  wound,  which  has  healed  and 
the  cicatrix  afterward  yields.  In  this 
case  the  external  coat  of  the  artery  and 
its  sheath  form  a  true  sac. 

A  circumscribed  traumatic  aneurism  is 
a  variety  wherein  condensation  of  the 
surrounding  cellular  tissue  has  formed 
an  adventitious  sac  for  the  blood.  Cir- 
cumscribed traumatic  aneurism  is  usu- 


ANEURISM.    CIRSOID. 


337 


ally  due  to  punctured  wounds  of  small 
arteries. 

A  diffused  traumatic  aneurism  may  be 
caused  in  three  ways:  (1)  by  healing  of 
the  cutaneous  woimd  before  the  arterial 
wound  heals;  (2)  by  a  subcutaneous  in- 
jury to  the  artery  without  a  skin  wound; 
(3)  later  on,  due  to  a  bruise  caused  by  a 
projectile  or  instrument,  the  bruised  spot 
yielding  when  the  remainder  of  the  in- 
jury was  healed. 

A  diffused  traumatic  aneurism  should 
not  be  considered  an  aneurism;  it  is,  in 
realitjf,  but  a  collection  of  arterial  blood 
in  the  tissues,  not  in  communication  with 
the  exterior,  like  an  ordinary  wounded 
artery. 

Protrusion  of  the  inner  coats  of  an 
artery  through  a  wound  oi  the  outer  coat 
is  called  a  hernial  aneurism.  It  is  ex- 
ceedingly uncommon. 

Diagnosis.  —  That  a  traumatic  aneu- 
rism may  cause  an  abscess  should  be 
borne  in  mind;  on  the  other  hand,  an 
imcomplicated  traumatic  aneurism  may 
resemble  an  abscess.  A  positive  diag- 
nosis may  be  arrived  at  by  the  history 
of  the  case,  and  by  withdrawing  some 
of  the  contents  with  an  asepticized  hypo- 
dermic needle.  Pus  will  be  found  if  an 
abscess  is  present,  and  fluid  blood  if  an 
aneurism. 

Treatment.  —  The  treatment  of  trau- 
matic aneurism  varies  according  to  its 
location.  It  should  be  treated  like  a 
primary  wound  of  an  artery. 

Where  possible,  as  on  a  limb,  an  Es- 
march  bandage  should  be  applied,  the 
injured  artery  exposed  by  incision,  com- 
pletely divided.  Both  ends  of  the  vessel 
are  then  tied.  Every  effort  should  be 
made  to  obtain  primary  union. 

When  the  aneurism  is  located  in  a 
region  where  Esmarch's  bandage  cannot 
be  used,  as  on  the  neck,  the  tumor  should 
be  exposed,  and  an  opening  made  just 


large  enough  to  introduce  one  finger, 
which,  guided  by  the  current  of  warm 
arterial  blood,  should  be  carried  to  the 
artery  leading  to  the  aneurism. 

Six  cases  in  which  aneurism  of  the 
arch  of  the  aorta  and  of  the  base  of 
the  neck  by  the  simultaneous  ligation 
of  the  right  carotid  and  subclavian 
arteries.  But  one  death  occurred:  due 
to  hemiplegia.  In  this  case  the  arteries 
on  the  left  side  were  not  permeable,  and 
so  could  not  furnish  blood  to  the  brain. 
Thiombosis  occurred.  Ligation  of  the 
right  carotid  should  never  be  performed 
when  the  left  carotid  and  its  branches 
no  longer  pulsate. 

The  operation  is  not  dangerous,  pro- 
vided a  completely  aseptic  ligature  is 
used.  Blacque  and  A.  Guinard  (Ann. 
Mai.  de  I'Or.,  Nov.,  '96). 

Traumatic  aneurism  of  the  ulnar 
artery  in  the  palm  cured  by  tying  the 
ulnar  artery  above  the  wrist.  William 
Robertson  (Brit.  Med.  Jour.,  Dee.  4,  '97). 

Two  cases  of  traumatic  aneurism  of 
the  radial  artery,  treated  by  excision  of 
the  sac.  Recovery.  Elevation  of  the 
limb,  combined  with  pressure  on  the  sac, 
will  sometimes  effect  a  cure,  but  at  best 
it  is  tedious  in  its  application  and  un- 
certain in  its  results.  Simple  ligation 
of  the  vessel  above  and  below  the  sac  is 
more  likely  to  prove  successful.  Ex- 
cision effectually  cures  the  disease,  and  is 
easily  performed  if  the  sac  be  of  small 
size.  Non-removal  of  the  tourniquet, 
until  the  dressing  and  bandaging  of  the 
Mound  are  completed,  is  a  valuable  detail. 
J.  E.  Piatt  (Med.  Chronicle,  Dec,  '97). 

Cirsoid  Aneurism. 

As  compared  to  the  forms  of  aneurism 
already  described,  this  variety  is  very 
rarely  met  with.  It  should  be  classed 
with  tumors,  being,  in  reality,  an  arterial 
angioma. 

Varieties.  —  Where  a  single  vessel  is 
involved,  it  is  usually  called  an  arterial 
varix;  when  a  number  of  vessels  are 
included  in  the  mass,  it  is  termed  cirsoid 
aneurism;  and,  when  the  surroimding 
veins  and  capillaries  are  also  dilated,  the 


338 


ANEURISM.     CIRSOID.    SYMPTOMS.    TREATMENT. 


name  aneurism  by  anastomosis  is  applied 
to  the  irregular  mass  thus  formed. 

Symptoms.  —  Although  cirsoid  aneu- 
risms may  be  met  with  in  any  part  of  the 
body,  their  site  of  predilection  is  the 
head  especially,  and  more  particularly 
the  temporo-parietal  region.  The  hands 
come  next  in  the  order  of  frequency.  A 
cirsoid  aneurism  appears  as  an  irregu- 
larly-shaped, bluish,  and  flattened  mass 
of  dilated  blood-vessels,  twisted  inextri- 
cably together,  from  which  project  am- 
pulla, or  bags.  The  skin  over  this  is 
extremely  thin,  soft,  and  doughy  to  the 
touch,  and  is  in  imminent  danger  of 
rupture.  Manual  examination  shows  that 
it  is  connected  with  the  arterial  system, 
synchronous  pulsation  with  the  heart  be- 
ing evident.  Its  temperature  is  generally 
higher  than  that  of  the  surface  of  the 
body,  owing  to  the  increased  rapidity  of 
the  circulation  through  the  tortuous  an- 
eurismal  channels.  It  is  easily  emptied 
by  pressure,  but  immediately  fills  as  soon 
as  released.  A  distinct  thrill  may  gener- 
ally be  heard  over  it,  which  can  be  traced 
along  its  branches.  It  does  not  give  rise 
to  pain  imless  a  nerve  is  involved  in  the 
absorptive  process  which  cirsoid  aneu- 
risms give  rise  to  in  the  surrounding 
structures.  To  this  process  is  due  the 
grooves  found  in  bone  underlying  them 
and  the  thinness  of  the  skin  covering 
them. 

Diagnosis.  —  When  the  discoloration 
and  the  general  outline  of  the  growth 
present  does  not  at  once  establish  its 
identity,  a  true  aneurism  may  be  simu- 
lated. True  aneurism,  however,  is  usu- 
ally found  upon  an  artery  of  considerable 
size,  such  as  the  carotid,  the  tracheal, 
and  the  popliteal,  and  does  not  yield  so 
readily  to  pressure.  The  bosselated  out- 
line of  cirsoid  is  replaced  by  a  regular 
globular  mass.  The  peculiar  doughy  sen- 
sation communicated  to  the  hand  during 


palpation  is  peculiar  to  cirsoid  growths. 
Again,  these  are  habitually  situated  in 
the  extremities  where  medium  or  small 
arteries  are  to  be  found. 

Pathology. — Cirsoid  aneurisms  usually 
occur  as  the  result  of  traumatism.  This 
is  thought  to  give  rise  to  paralysis  of  the 
vasomotor  nerves  supplying  the  region 
affected,  and  thus  allowing  the  blood- 
vessels to  be  dilated.  It  has  been  known 
to  start  from  a  nsevus,  and  it  has  been 
traced  to  an  arteritis.  In  the  majority 
of  cases,  however,  its  origin  cannot  be 
ascertained.  As  already  stated,  it  be- 
longs more  properly  to  true  tumors,  and 
should  be  termed,  according  to  Tillmann, 
"angioma  arteriate  racemosa." 

Cirsoid  aneurisms  believed  to  be  due 
to  arteritis,  whicli  weakens  the  vessel- 
walls  and  allows  their  dilatation.  Ar- 
teritis explains  all  cases  of  cirsoid  aneu- 
rism following  an  injury;  those  follow- 
ing nsevi  can  be  explained  by  a  congeni- 
tal defect  of  nutrition  of  the  walls  of  the 
vessels.  J.  L.  Reverdin  (Rev.  Med.  de  la 
Suisse,  Feb.  20,  '98). 

Cirsoid  aneurism  is  most  frequently 
found  on  the  scalp  and  face,  but  it  may 
likewise  be  found  in  the  tongue,  extrem- 
ities, internal  viscera,  and  bones. 

Prognosis. — Although  a  cirsoid  aneu- 
rism may  not  grow  or  change  for  many 
years,  it  may  also  steadily  develop  in  size 
and  spread  by  invading  the  vessels  of  the 
surrounding  tissues.  The  thinness  of  the 
overlying  skin  presents  constant  danger, 
and  rupture  of  one  of  the  ampullaa  may 
give  rise  to  uncontrollable  hemorrhage. 

Treatment.  —  Eemoval  by  excision  is,, 
by  far,  the  best  procedure  to  use,  with 
complete  arrest  of  the  hemorrhage  by 
ligation  of  the  afferent  and  efferent  ves- 
sels. Among  the  other  measures  recom- 
mended have  been  ligation  of  the  various 
afferent  arteries,  coagulation  of  the  blood 
by  means  of  various  injections,  the  gal- 
vanocautery,   electropuncture,   and    acu- 


ANEUEISM.    ARTERIO-VENOUS. 


339 


pressure.  But  none  of  these  afford  satis- 
factory results  in  the  great  majority  of 
cases.  In  multiple  cirsoid  of  the  hand 
or  other  extremities,  amputation  some- 
times becomes  necessary. 

Case  of  extensive  cirsoid  aneurism  of 
the  scalp,  cured  by  multiple  ligatures. 
Mynter  (Annals  of  Surg.,  Feb.,  '90). 

Case  of  cirsoid  aneurism  with  liga- 
ture of  the  common  carotid  artery. 
Decided  improvement,  notwithstanding 
heavy  work.  W.  D.  Hamilton  (N.  Y. 
Med.  Jour.,  Kov.  3,  '94). 


Fig.   1. — Diagi-am  of  aneurismal  varix. 
a,  Artery;    v,  Vein. 

Successful  result  in  a  case  of  large 
cirsoid  aneurism  of  the  scalp.  Blood- 
supply  controlled  by  acupressui'e-pins 
applied  to  external  terminal  branches  of 
nutrient  arteries.  Subsequent  crucial  in- 
cision and  vascular  tissue  entirely  re- 
moved between  the  skin  and  periosteum 
of  flat  bones.  Compression  applied; 
complete  recovery.  W.  S.  Forbes  (Med. 
News,  June  15,  "95). 

Case  of  cirsoid  aneurism  of  the  scalp; 
ligature  and  acupressure  followed  by  im- 
mediate and  complete  excision;  recovery. 
J.  J.  Pratt  (Lancet,  .July  3,  '97). 


Cirsoid  aneurism  of  the  scalp  follow- 
ing a  fall  against  a  curb.     In  spite  of 
the     probable     haemorrhage,     the     best 
treatment  in  this  location  is  excision  of 
the  aneurism  entire.    The  child  was  well 
in  a  week.    Broca  (Jour,  de  Chir.,  Apr.- 
May,  1901). 
Arterio-venous  Aneurism. 
Varieties. — An  artery  and  a  vein  may 
intercommunicate  in  two  ways:  (1)  when 
the  one  vessel  opens  into  the  other  by  a 
short  channel — the  so-called  aneurismal 
varix — and   (2)  when  between  the  two 


Fig.  2. — Diagram  of  varicose  aneurism. 
a,  Artery ;  v.  Vein ;  s.  Sac,  containing- 
a  laminated  clot  on  each  side  of  the 
channel;    *,  Intervaseular  tissues. 

vessels  there  is  an  adventitious  sac:  the 
so-called  varicose  aneurism.  Although 
both  terms  are  incorrect  and  misleading, 
they  serve  to  establish  a  distinction  which 
becomes  important  when  the  treatment 
is  considered,  the  measures  indicated  in 
aneurismal  varix  being  dangerous  in  vari- 
cose aneurism. 

The  difference  between  the  two  varie- 
ties is  illustrated  in  the  wood-cuts  printed 
above. 


340 


ANEUPaSM.    ARTERIOVENOUS.    SYMPTOMS.    ETIOLOGY. 


Symptoms. — The  receipt  of  the  injury 
may  be  attended  by  syncope  if  internal 
vessels  are  woimded,  but  superficial  ves- 
sels are  by  far  those  most  frequently  in- 
volved, and  aneurismal  varix  may  last  for 
years  without  serious  disturbance.  The 
most  common  situation  of  this  variety 
is  the  bend  of  the  elbow,  the  result  of 
punctured  wounds  which  penetrate  both 
vessels. 

A  whirring  sound,  like  the  purring 
of  a  kitten,  is  produced  by  the  current 
passing  from  the  artery  into  the  vein. 
This  sound  was  compared  by  Spence  to 
the  noise  made  by  a  fly  in  a  paper  bag. 
It  is  more  distinct  above  than  below  the 
tumor,  and  the  limb  is  usually  somewhat 
weaker  and  colder  than  is  natural.  A 
thrill  is  felt  when  the  hand  is  applied 
over  the  tumor. 

In  varicose  aneurism  there  exists,  as 
already  stated,  a  sac  between  the  two 
vessels;  but  it  is  important  to  remember 
that  this  sac  is  not  constituted  of  the 
coats  of  the  vessels  involved;  it  is  an 
artificial  formation  at  the  expense  of 
the  tissues  between  the  vessels.  These 
having  been  simultaneously  wounded, 
the  lymph  effused  in  the  course  of  the 
inflammatory  process  forms  a  partition 
to  limit  the  extravasation.  This  extrav- 
asation differs  from  that  of  a  false  aneu- 
rism in  that  it  communicates  with  a  vein. 

The  difference  between  aneurismal 
varix  and  varicose  aneurism  consists, 
besides  the  presence  of  the  adventitious 
sac,  of  a  greater  length  of  the  interven- 
ing canal  in  varicose  aneurism.  A  lami- 
nated clot  on  each  side  of  this  canal  con- 
tributing also  to  reduce  its  diameter  to 
that  of  the  canal  in  aneurismal  varices, 
taken  as  a  whole,  the  symptoms  of  both 
conditions  are  about  similar.  Palpation 
sometimes  makes  it  possible  to  detect  the 
presence  of  the  intervening  sac,  and  also, 
in   addition   to   the   thrill   and  buzzing 


sound  of  aneurismal  varix,  a  distinct  im- 
pulse. An  aneurismal  murmur  or  soft 
bruit  may  frequently  be  elicited.  The 
conformation  of  varicose  aneurism  is  not 
such  as  to  tend  toward  much  enlarge- 
ment. 

If,  according  to  Tillmann,  the  point  of 
communication  between  the  artery  and 
vein  be  compressed,  the  pulsation  in  the 
dilated  and  tortuous  vessels  ceases,  and 
they  collapse. 

The  limb  is  generally  wasted  below  the 
varix  if  the  case  is  one  of  long  standing; 
it  may  also  be  cedematous,  hard,  and  en- 
larged. 

In  twenty-nine  cases  of  aneurism  of 
the  ascending  arch  of  the  aorta  opening 
into  the  vena  cava  analyzed  by  Pepper 
and  Griffith,  a  thrill  was  observed  in 
some  cases;  in  others  a  continuous  mur- 
mur with  systolic  increase,  with  sudden 
development  of  cyanosis,  oedema,  and  en- 
gorgement of  the  veins  of  the  upper  part 
of  the  body. 

Case  of  traumatic  arterio-venous  an- 
eurism of  the  arch  of  the  aorta  and  the 
innominate  vein.  The  thrill  was  most 
distinct  over  the  manubrium  sterni,  and 
could  be  follo\yed  down  the  internal 
jugular  and  left  brachial  veins  and  over 
the  skull  in  the  course  of  the  sinuses. 
The  autopsy  showed  an  opening  in  the 
arch  of  the  aorta  between  the  points  of 
origin  of  the  carotid  and  the  innominate 
arteries,  which  communicated  directly 
with  the  left  innominate  vein:  dilated 
at  this  point  to  the  size  of  an  orange. 
Long  survival  after  the  accident  is 
worthy  of  notice.  Colzi  (Lo  Speri- 
mentale,  Feb.,  '95). 

Etiology.  —  Both  varieties  are  caused 
by  traumatisms  by  which  an  artery  and 
vein  in  juxtaposition  are  wounded  simul- 
taneously from  a  stab  or  in  phlebotomy. 
Arterio-venous  aneurisms  were  much 
more  frequent  when  venesection  was  in 
vogue  than  they  are  now  that  this 
procedure  is  rarely  resorted  to. 


ANEURISM.    ARTERIO-VENOUS.    PATHOLOGY.    TREATMENT. 


341 


A  true  aneurism  may  gradually  ad- 
here to  a  vein,  and  give  rise  to  an  arterio- 
venous aneurism. 

Case  of  spontaneous,  probably  eon- 
genital,  arterlo-venous  aneurism  of  the 
arm  and  hand,  caused  by  an  abnormal 
communication  between  the  common  in- 
terosseous artery  and  a  deep  branch  of 
the  cephalic  vein.  Ligature  of  the  bra- 
chial artery  followed  by  gangrene  of  the 
forearm  and  hand;  amputation;  recov- 
ery. Weidemann  {Beitriige  zur  klin. 
Chir.,  Sept.   15,  '93). 

Pathology.  —  Besides  the  features  al- 
ready noted  is  the  fact  that  the  wound 
between  the  vessels  does  not  heal,  so  that 
at  each  pulsation  a  certain  amount  of 
blood  is  forced  through  from  the  artery 
into  the  vein.  The  latter  pulsates 
strongly  and  becomes  tortuous  and  di- 
lated; the  veins  beyond  the  aneurismal 
varix  on  the  limb  are  likewise  dilated. 
The  artery  is  more  or  less  dilated  above, 
but  much  contracted  below,  the  lesion. 

Prognosis. — An  aneurismal  varix  may, 
as  already  stated,  cause  no  very  serious 
disturbance,  and  is  not,  therefore,  re- 
garded as  a  dangerous  condition.  This 
is  not  the  case,  however,  with  varicose 
aneurism,  as  the  intervening  sac  may  at 
any  moment  become  disorganized  and 
give  rise  to  a  diffuse  aneurism.  The 
varicose  veins  may  also  become  greatly 
enlarged,  and  be  followed  by  cedema  and 
perhaps  gangrene. 

Case  of  fourteen  years'  standing, 
caused  by  a  punctured  wound  of  the 
axilla.  Arm  normal,  veins  not  dis- 
tended, function  perfect,  but  all  over  the 
arm  the  characteristic  bruit  could  be 
heard;  operation  contra-indicated.  Osier 
(Annals  of  Surgery,  Jan.,  '92). 

Case  of  aneurismal  varix  of  the  left  in- 
ternal carotid  artery  and  the  cavernous 
sinus.  It  has  remained  unaltered  for 
twenty-three  years.  C.  E.  Williamson 
(Brit.  Med.  -lour.,  Oct.  13,  "94). 

Fourteen  cases  of  arterio-venous  aneu- 


rism of  subclavian  published.  Case  in 
which  there  was  no  syncope  at  the  time 
of  accident  and  seven  months  after  de- 
velopment of  aneurism  no  functional 
trouble.  Wedenkind  (Deutsche  med. 
Woch.,  No.  16,  '95). 

Treatment.  —  In  the  majority  of  cases 
aneurismal  varix  requires  no  treatment, 
or  no  more  than  the  application  of  an 
elastic  bandage  to  prevent  its  growth. 

Where  extension  of  the  affection 
causes  pain  and  disturbance  in  the  cir- 
culation, compression  may  be  applied 
above  and  below  and  upon  the  tumor 
itself;  should  this  not  succeed,  the  artery 
and  vein  can  be  tied  above  and  below 
the  opening,  and  the  aneurism  removed. 
It  is  only  when  absolutely  necessary  that 
aneurismal  varix  of  the  femoral  vessels 
or  of  the  carotid  and  internal  jugular 
should  be  submitted  to  operative  pro- 
cedures. 

Unlike  aneurismal  varix,  varicose  an- 
eurisms, as  stated,  present  an  element  of 
danger:  the  intermediate  sac,  owing  to 
its  histological  composition,  tending  to 
ulcerate  at  any  moment  and  to  give  rise 
to  a  difiuse  aneurism.  Pressure  is  ob- 
viously contra-indicated;  it  would  cause 
enlargement  of  the  already  dilated  veins 
and  probably  give  rise  to  cedema  and 
gangrene.  The  best  treatment,  especially 
when  the  aneurism  is  small,  is  to  tie  both 
vessels  above  and  below  the  aneurism, 
and  to  remove  the  latter. 

Case  in  which  arterio-venous  aneurism 
followed  a  wound  of  the  popliteal  artery 
and  vein  by  a  spicule  of  glass.  Operation 
was  performed  four  and  one-half  weeks 
after  the  accident.  The  sac  was  opened, 
both  vessels  discovered  to  be  injured,  and, 
after  an  unsuccessful  attempt  to  close 
the  vein  by  suturing,  both  were  ligated. 
Of  7  cases  of  simultaneous  ligation  of 
the  popliteal  artery  and  vein,  in  6  of 
which  these  vessels  had  been  Avounded, 
all  recovered,  1  after  amputation  for  gan- 
grene.   In  8  other  cases  the  results  Avere 


342 


AifEURISM. 


ANGINA  PECTORIS. 


entirely     favorable.       G.     P.     Newboldt 
(Lancet,  Apr.  23,  '98). 

In  varicose  aneurism  of  tlae  neck  or 
femoral  vessels,  it  is  best  to  cut  down 
upon  the  artery  below  and  above  the  sac 
and  ligate  without  touching  the  vein  or 
the  sac.  This  method  was  suggested  by 
Spence,  of  Edinburgh. 

In  cutting  down  upon  a  varicose  an- 
eurism, the  incision  intended  to  open 
the  enlarged  vein  should  be  followed  by 
one  opening  the  sac,  so  as  to  bring  the 
aperture  within  the  artery  into  the  field 
of  operation. 

Hunter's  method  of  ligating  the  artery 
above  the  sac  is  not  successful,  as  the 
unimpeded  circulation  of  blood  into  the 
sac  through  the  vein  prevents  coagiila- 
tion  of  the  fibrin.  In  a  general  way,  it 
may  be  said  that  all  small  aneurisms,  not 
involving  the  larger  vessels  of  a  limb, 
should  be  extirpated,  unless  important 
nerves  are  jeoparded  by  the  dissection, 
or,  as  on  the  face,  where  it  is  important 
to  not  leave  a  scar.  The  treatment  se- 
lected for  larger  aneurisms  depends  upon 
their  situation.  Those  of  the  neck  which 
involve  the  external  jugular  vein  will 
rarely  require  treatment,  but,  should  it 
be  necessary,  such  cases  are  best  treated 
by  double  ligation  of  both  vessels.  In 
other  situations  the  simple  ligature  of 
the  vessels  should  not  be  chosen,  for  it 
will,  in  most  cases,  require  as  much  dis- 
section as  will  incision  or  extirpation, 
while  not  giving  the  same  immunity 
from  relapse.  The  surgeon  should  make 
an  incision  down  upon  the  sac  in  its 
entire  length,  and  attempt  to  dissect  it 
from  its  bed.  If  this  prove  difficult  or 
impossible  because  of  inflammatory  thick- 
ening or  intimate  connection  with  impor- 
tant parts,  the  sac  should  be  incised,  for 
it  is  often  easier  to  secure  the  vessels 
when  the  sac  is  freely  opened.  The  sac 
could  then  be  left  entirely  in  place  or 


it  could  be  partly  removed.  Suture  and 
simple  drainage  of  the  sac  have  been 
found  sufficient,  and  it  is  unnecessary  to 
resort  to  packing.     (Farquhar  Curtis.) 

J.  McFadden  Gaston, 

J.  McFadden  Gaston,  Je., 

Atlanta. 

ANGINA  PECTOEIS. 

Definition.  —  Angina  pectoris  (steno- 
cardia, breast-pang)  is  the  name  given 
to  a  group  of  symptoms  which  usually 
depends  upon  organic  disease  of  the 
heart  or  aorta.  An  attack  consists  in 
the  sudden  onset  of  agonizing  pain  in 
the  praecordial  or  sternal  regions,  accom- 
panied by  a  feeling  of  constriction  and 
in  severe  cases  by  a  sense  of  impending 
death.  The  pain  radiates  into  the  back, 
the  shoulders,  and  the  arms,  particularly 
the  left.  The  patient  is  pale,  haggard, 
motionless,  and  often  bathed  with  cold 
perspiration. 

Symptoms. — Suddenly,  after  exertion, 
excitement,  or  a  hearty  meal,  the  patient 
feels  an  excruciating,  burning,  or  tearing 
pain  in  the  heart  or  beneath  the  sternum, 
accompanied  with  a  sense  of  constriction 
{angere,  to  throttle),  as  if  the  heart  were 
in  a  vise.  The  pain  radiates  into  the 
back,  upward  into  the  shoulders,  and 
down  the  left  arm,  often  even  to  the 
finger-tips.  It  may  be  felt  in  both  arms, 
in  the  neck  and  head,  and  even  in  the 
trunk  and  lower  extremities.  "In  true 
angina  the  seat  of  the  pain  may  be  en- 
tirely way  from  the  chest,  and  may  be, 
as  in  Lord  Clarendon's  father,  at  the 
inner  aspect  of  the  arm,  or  about  the 
wrist,  or  in  rare  instances  confined  to  the 
side  of  the  neck,  or  even  to  one  testis." 
(Osier.) 

Attacks  occur  in  which  pain  is  slight 
or  absent  (angina  sine  dolore).  Early 
attacks  are  often  of  this  sort.    At  a  later 


ANGINA  PECTORIS.    SYMPTOMS. 


343 


period  there  may  still  be  no  pain,  or  the 
paroxysms  may  sometimes  be  painful  and 
at  other  times  not. 

A  feeling  of  numbness  accompanies 
the  pain.  There  is  a  sense  of  impending 
dissolntion.  The  sufferer  sits  or  stands 
immobile  and  hardly  dares  to  breathe. 
Yet  there  is  no  real  dyspnoea.  The  face 
is  pale  or  livid,  the  forehead  wet  with 
perspiration.  The  pulse  may  remain 
strong  and  regular.  Usually  it  is  accel- 
erated and  of  increased  tension.  It  may 
intermit  or  vary.  Exceptionally  it  is 
slowed.  The  paroxysm  lasts  a  few  sec- 
onds or  minutes, — sometimes  half  an 
hour  or  even  several  hours.  At  the  end 
of  it  the  patient  often  belches  gas  or 
vomits  or  has  a  movement  of  the  bowels, 
with  great  relief.  The  attack  may  prove 
immediately  fatal.  If  not,  the  patient 
is  left  exhausted,  but  regains  his  usual 
condition  in  a  few  hours  or  days. 

Study  of  twenty-one  cases.  The  at- 
tacks usually  came  on  after  a  meal.  In 
every  case  exertion  increased  the  pain, 
and  the  sense  of  fullness  was  relieved 
by  the  eructation  of  gas.  Most  of  the 
patients  attributed  their  trouble  to  in- 
digestion. In  all  there  was  shallow 
respiration  with  an  occasional  deep  in- 
spiration. The  heart  was  usually  slow, 
occasionally  palpitating  or  irregular, 
and  the  pulse  was  generally  tense  and 
sustained.  In  all  arterial  fibrosis  could 
be  recognized  by  a  thickening  of  the 
palpable  arteries;  cardiac  disease — 
manifested  by  accentuation  of  the  sec- 
ond aortic  tone,  feebleness  of  the  first 
sound,  cardiac  murmurs,  etc. — was  pres- 
ent at  some  time  in  nearly  all  cases. 
During  the  attacks  the  second  aortic 
sound  was  always  much  accentuated, 
while  the  first  sound  could  be  heard 
very  indistinctly.  Frank  Billings  (Chi- 
cago Med.  Recorder,  Feb.,  1901). 

The  attack  is  almost  sure  to  be  re- 
peated. This  may  happen  in  an  hour 
or  not  for  weeks  or  months.    The  lensrth 


of  the  interval  depends  greatly  upon  the 
persistence  of  the  patient  in  avoiding  the 
exciting  causes.  Successive  paroxysms 
occur  with  gradually  increasing  readi- 
ness. 

Angina  pectoris  is  probably  due  to 
increased  intravascular  pressure.  We  can 
reasonably  infer  the  presence  of  dilata- 
tion of  the  heart  by  the  physical  signs 
of  displaced  apex-beat;  gallop-rhythm;  a 
soft,  regurgitant  murmur  in  the  tricuspid 
or  mitral  area;  by  venous  phenomena; 
and  by  the  congestions,  cyanosis,  and 
dropsy  that  attend  this  affection.  The 
results  of  cardiac  percussion  may  be  con- 
firmatory, but  are  not  looked  upon  as 
essential  in  the  diagnosis  of  cardiac  dila- 
tation. Five  cases  to  illustrate  the  fol- 
lowing propositions: — 

1.  Wben  dilatation  of  the  heart  super- 
venes in  a  patient  the  subject  of  an 
attack  or  attacks  of  angina  pectoris,  the 
subjective  symptoms  may  subside.  At 
the  same  time  the  physical  type  of  the 
individual  changes. 

2.  Angina  pectoris  may  occur  in  a 
patient  who  has  had  dilatation  of  the 
heart  when  the  organic  condition  (dila- 
tation) is  removed  by  treatment.  J.  H. 
Musser  (Amer.  Jour,  of  Med.  Sciences, 
Sept.,  '97). 

Attention  drawn  to  that  form  which 
is  found  in  association  with  dry  pericar- 
ditis: the  pain  in  these  cases  is  situated 
at  the  base  or  middle  of  the  sternum;  It 
may  also  be  in  the  epigastrium  and  over 
the  cardiac  area.  It  radiates  outward 
toward  the  arms.  These  signs,  in  truth, 
afford  no  differentiating  clue.  On  careful 
auscultation,  however,  to-and-fro  friction 
may  be  heard  coincidently  with  the  car- 
diac movements,  with  hyperfesthesia  in 
the  prEecordial  region;  and  the  facts  of 
its  frequently  following  tonsillitis  and 
rheumatic  ailments,  and  not  being  amen- 
able to  the  operation  of  vasodilators  and 
stimulants,  serve  to  distinguish  it  from 
most  cases  of  coronary  angina:  it  is  an 
exocardial  angina.  The  treatment  of  the 
condition  is,  naturally,  that  of  pericar- 
ditis. M.  Pawinski  (La  Semaine  M6d., 
Oct.  6,  '97). 

Special  variety  of  musical  heart-mur- 


344 


ANGINA  PECTORIS.    DIAGNOSIS. 


mur,  resembling  a  feeble  groan  or  chirp- 
ing of  chickens.  Similar  cases  described 
by  Capozzi,  in  which  a  constant  lesion 
was  found,  namely:  a  regular  perfora- 
tion of  a  free  valve.  Case  of  a  man, 
aged  30,  suffering  from  anginal  attacks. 
Double  aortic  murmur,  the  diastolic  part 
of  the  murmur  being  musical.  The  apex- 
beat  was  in  the  fifth  space,  outside  the 
nipple-line.  No  history  of  rheumatism. 
History  of  syphilis.  Death  in  one  of  the 
attacks  of  angina.  At  autopsy  mitral 
valves  found  normal;  aortic  valves 
thickened,  two  cusps  being  adherent; 
the  third  was  perforated  near  the  aortic 
parietes,  but  not  adherent.  Coronary 
arteries  healthy.  Tecce  (La  Eif.  Med., 
Apr.  2,  '97). 

Diagnosis.  —  In  true  angina  pectoris 
skilled  observers  almost  invariably  find 
evidence  of  organic  cardiac  or  aortic  le- 
sion. In  a  supposed  case  these  should  be 
sought  most  carefully.  Particularly  to 
be  looked  for  are  arteriosclerosis,  hyper- 
trophy or  dilatation  of  the  left  ventricle, 
aortic  regurgitation,  and  feebleness  of 
the  muscular  power  of  the  heart. 

True  angina  always  associated  with 
cardiac  lesions,  especially  of  the  coronary 
arteries;  but  the  absence  of  physical 
signs  do  not  always  affect  the  diagnosis, 
as  it  frequently  occurs  that  the  lesions 
are  only  discovered  after  death.  Pre- 
sumptive signs  which  deserve  atten- 
tion:— 

The  age  of  the  patient;  true  angina  is 
very  rare  before  forty. 

The  pain  commences  always  in  the 
heart,  while  in  pseudo-angina  it  is  as- 
cribed to  the  arm  and  radiates  in  several 
directions. 

The  infrequency  of  the  attacks  in  true 
angina,  the  patient  being  liable  to  suc- 
cumb in  the  second  or  third  attack. 

True  angina  is  provoked  by  effort, 
emotion,  and  disorders  of  digestion. 

It  occurs  in  the  day-time,  while  in 
false  angina  the  attacks  are  generally 
nocturnal. 

Patients  suffering  from  true  angina 
are  pale  and  can  neither  stir  nor  breathe. 
In  the  false  angina  he  is  agitated,  gets 


up  from  bed,  and  runs  to  the  window  for 
fresh  air.  Rendu  (Med.  Press  and  Cir- 
cular, July  22,  '96). 

Diagnosis   of   angina    pectoris    due   to 
disease   of  the  coronary   arteries,   based 
upon    retrosternal    pain,   with    tendency 
to  radiate;    a  sensation  of  anguish  and 
fear  of  imminent  death;    the  tendency  of 
the  attack  to  be  excited  by  exertion,  by 
emotion,   or  by   exposure  to   cold.     The 
pain  is  similar  to  that  experienced  in  a 
limb   the   main   artery   of  which   is,   by 
atheroma,' diminished  in  calibre.     Owing 
to  the  defective  supply  of  arterial  blood, 
the  heart  contracts  in  a  manner  painful 
to  the  patient,  the  peripheral  nerve  dis- 
tributions wanting  a  due  supply  of  oxy- 
gen.     P.    Merklen    (La    Semaine    Med., 
Aug.  9,  1900). 
Intebcostal  neuealgia  causes  pain 
along  an  intercostal  nerve,  not  radiating 
as  in  angina  pectoris.    It  presents  points 
tender  to  pressure  near  the  vertebrae  and 
sternum  and  in  the  axilla.    It  is  not  asso- 
ciated with  disordered  circulation. 

Gastealgia  is  apt  to  occur  when  the 
stomach  is  empty.  The  pain  does  not 
stream  into  the  shoulder  and  arm.  While 
there  may  be  collapse  and  a  sense  of  im- 
pending death,  there  is  no  evidence  of 
heart  disease.  Both  gastralgia  and  in- 
tercostal neuralgia  are  likely  to  occur 
in  anemic  young  women,  rather  than  in 
middle-aged  men. 

On  the  other  hand,  the  pain  of  true 
angina  pectoris  may  be  felt  lower  down 
than  the  prtecordia. 

As  already  stated,  the  termination  of 
an  attack  may  be  marked  by  the  dis- 
charge of  gas.  Particularly  if  there  is 
no  extreme  cardiac  pain,  this  may  lead 
the  patient,  and  in  some  instances  has 
led  his  physician,  astray. 

It  is  important  to  bear  in  mind  that 
symptoms  of  cardiac  embarrassment  as- 
suming the  character  of  "angina  sine 
doTore"  may  be  described  by  the  patient 
as  arising  from  dyspepsia.  These  pa- 
tients ascribe  their  discomfort  to  flatu- 
lent distension,  and  they  do  so  from  the 


ANGINA  PECTORIS.    ETIOLOGY. 


345 


well-known  fact  that  a  discharge  of 
flatus  gives  relief  to  the  uncomfortable 
sensation.  It  is  well,  in  advanced  middle 
life,  to  pay  rather  more  than  ordinary 
attention  to  flatulent  discomfort  coming 
on  after  food  or  exertion.  A  careful  e.\- 
amination  will  often  solve  the  problem 
and  will  conclusively  prove  that  the 
symptoms  are  rather  those  of  cardiac 
inefficiency  than  of  stomach  trouble. 
D.  W.  C.  Hood  (London  Lancet,  Sept.  26, 
'96). 

Cardiac  asthma  is  dyspnoea  due  to 
a  weak  heart  and  occurring  more  or  less 
paroxysmally.  Pain  is  not  prominent. 
The  picture  is  apt  to  include  pulmonary 
cedema,  enlarged  liver,  and  dropsy,  and 
it  could  hardly  be  mistaken  for  angina 
pectoris.  It  should  be  remembered,  how- 
ever, that  angina  may  attack  a  person 
who  is  already  suffering  from  failing 
compensation. 

Pseudo-angina  pectoris,  or  hysterical 
angina,  occurs  in  females  or  neurasthenic 
men,  usually  under  the  age  of  40,  with- 
out evidence  of  organic  cardio-vascular 
changes.  There  are  low  tension,  feeble 
second  sound,  and  soft  arteries.  The 
attacks  are  spontaneous  and  are  apt  to 
be  nocturnal  and  periodic  (menstrual). 
They  last  an  hour  or  two,  being  more 
prolonged  than  the  true  paroxysms.  The 
patient  is  agitated,  writhes,  or  walks 
about  the  room,  and  talks.  The  heart 
feels,  not  constricted,  but  distended. 
The  pain  is  not  apt  to  be  so  severe  as 
in  true  angina  pectoris.  Parssthesiae 
and  vasomotor  symptoms  are  prominent. 
Death  never  occurs. 

Hysteria.  —  It  should,  of  course,  be 
remembered  that  hysteria  may  be  com- 
bined with  organic  disease,  and  that  a 
careful  physical  examination  should  be 
made  in  any  suspected  case;  but  the  dis- 
covery of  mitral  disease  would  not  be 
inconsistent  with  a  diagnosis  of  pseudo- 
angina. 


Syphilis.  —  A  history  of  syphilis  in 
a  man,  even  if  under  40  years  of  age, 
renders  the  occurrence  of  true  angina 
pectoris  less  improbable  than  it  other- 
wise would  be,  for  there  is  a  possibility 
of  syphilitic  aortitis  obstructing  the  ori- 
fices of  the  coronaries. 

Tobacco,  Tea,  etc.  —  Excess  in  to- 
bacco (less  often  alcohol,  tea,  and  cofEee) 
and  lead  poisoning  may  occasion  spurious 
angina,  or  again  they  may  aggravate  a 
genuine  paroxysm  depending  on  organic 
lesions. 

While  certain  cases  are  evidently  true 
angina  and  others  equally  obviously 
pseudo-angina,  some  are  extremely  puz- 
zling. 

Etiology.  —  j\Iales  over  40  years  of 
age  in  comfortable  worldly  circumstances 
make  up  the  majority  of  sufferers  from 
angina  pectoris.  Predisposing  causes  are: 
alcohol,  syphilis  (arteriosclerosis,  tabes 
dosalis),  rheumatism,  gout,  diabetes, 
chronic  nephritis,  and  influenza.  Some- 
times attacks  are  hereditary. 

As  exciting  causes  may  be  named : 
physical  exertion,  mental  strain,  pro- 
found emotion,  and  digestive  disturb- 
ances. The  attacks  may  come  in  the 
day-time,  especially  at  first;  but  some  of 
the  worst  occur  at  night;  so  that  finally 
they  may  make  the  patient  dread  going 
to  sleep. 

Angina  pectoris  due  in  part  to  the 
attitude  of  writing  in  haste,  in  part  to 
nervous  overexcitement.  The  attitude 
hampers  respiration,  and  by  compressing 
the  abdomen  interferes  with  the  move- 
ment of  the  diaphragm;  in  addition, 
there  is  a  kind  of  spasmodic  contraction 
of  the  fingers  which  is  communicated  to 
the  muscles  of  the  forearm,  arm,  and 
chest.  The  action  of  the  whole  heart, 
and  particularly  of  the  right  ventricle, 
is  impeded,  and  this  leads  to  some  degree 
of  venous  stasis,  which  would  provoke 
a  spasm  of  the  coronary  vessels  simulat- 


346 


ANGINA  PECTORIS.    PATHOLOGY. 


ing  an  attack  of  true  angina.  Musgrave 
(Semaine  Med.,  Jan.  25,  '99). 

Angina  pectoris  and  the  menopause. 
Attacks  of  angina  pectoris  observed  for 
the  first  time  at  the  menopause  may  be 
dependent  upon  the  changes  occurring 
at  this  period,  or  they  may  accidentally 
begin  at  this  time  from  other  and  unas- 
sociated  causes.  In  the  former  ease  the 
attacks  may  be  purely  neurasthenic  or 
hysterical,  or  they  may  be  of  vasomotor 
origin  (spasm  of  the  coronary  arteries), 
giving  the  picture  of  severe  organic  an- 
gina pectoris.  These  two  forms  may, 
of  course,  be  combined.  Th.  K.  Geisler 
(Vratch,  Feb.  12,  1900). 

While,  in  general,  the  vascular  origin 
of  angina  pectoris  cannot  be  denied, 
eases  occur  which  undoubtedly  are  due 
to  lesions  of  the  aortic  or  coronary 
plexus,  and  the  cases  cited  are  thought 
to  justify  the  belief  that  in  syphilitic 
angina  pectoris,  in  which  a  coronary 
stenocardia  might  be  considered  prob- 
able, there  exist  changes  in  the  aortic 
plexus  and  in  the  nerves  of  the  heart. 
This  alteration  of  aortic  or  cardiac 
plexus  may  be  in  the  nature  of  a  neu- 
ritis, or  may  be  due  to  changes  in  the 
vessels  of  the  nerves,  the  functional 
efTeets  of  which  would  be  equivalent  to 
a  lesion  of  the  nerve  proper.  Such 
changes  in  the  nerves  or  vasa  nervorum 
are  caused  by  a  terminal  obliterating 
endarteritis,  pericellular  infiltration,  or 
embryonic  gummata  which  irritate  the 
vessels.  These  changes  can,  in  the  large 
majority  of  cases,  be  controlled  by 
energetic  specific  treatment;  hence  the 
importance  of  early  etiological  diag- 
nosis. XJ.  Benenati  (La  Riforma  Medica, 
May  3,  5,  6,  and  7,  1902). 

Pathology. — It  is  exceptional  for  at- 
tacks of  tnie  angina  pectoris  to  be 
observed  in  persons  presenting  no  evi- 
dence of  organic  circulatory  lesion.  The 
commonest  underlying  conditions  are 
sclerosis  of  the  coronary  arteries,  degen- 
eration of  the  myocardium,  cardiac  hy- 
pertrophy, atheroma  of  the  aorta,  aneiT- 
rism  of  that  vessel  near  its  origin,  and 
aortic  regurgitation.    There  is,  however, 


"hardly  an  affection  of  the  walls  or  cavi- 
ties of  the  heart,  scarcely  a  morbid  con- 
dition of  the  arteries  that  nourish  it  or 
spring  from  it,  with  which  the  distress- 
ing malady  has  not  been  observed  to  be 
associated."    (Da  Costa.) 

Eecent  writers  lay  stress  on  oblitera- 
tion of  the  lumen  of  the  coronary  arter- 
ies as  the  essential  basis  of  true  angina 
pectoris,  which  obliteration  may  be  oc- 
casioned either  by  sclerosis  of  the  vessels 
or  by  changes  in  the  aorta  at  their  origin. 
"So  intimately  associated  is  the  true 
paroxysm  with  sclerotic  conditions  of  the 
coronary  arteries  that  it  is  extremely  rare 
apart  from  them."  (Osier.)  (Same  view. 
Whittaker.) 

Case  of  angina  pectoris  without  lesions 
of  the  coronaries  in  which  death  oc- 
curred during  a  paroxysm.  Aortic  and 
mitral  endocarditis  wa-s  found  post- 
mortem, but  no  lesion  whatever  of  the 
coronaries.  Numerous  personal  autop- 
sies on  the  bodies  of  old  people,  at  the 
Bicetre  Hospital,  where  there  had  been 
no  complaint  of  angina  during  life,  and 
yet  the  coronaries  were  found  to  be  al- 
most occluded  by  atheromatous  plaques. 
Pilliet  confirmed  these  observations.  He 
had  found  a  large  number  of  obstructed 
coronary  arteries  which  had  never  caused 
angina.  Auseher  (Bull,  de  la  See.  Anat., 
Oct.  9,  '91. 

The  immediate,  precipitating  condi- 
tions of  a  paroxysm  are  not  known,  but 
they  are  supposed  to  be  connected  with 
disturbances  of  the  vagus,  or,  perhaps, 
the  sympathetic  nerves.  Nothnagel  re- 
ported a  series  of  cases  under  the  title 
"Angina  Pectoris  Vasomotoria"  which 
seemed  to  be  due  to  a  pure  neurosis. 
They  followed  exposure  to  cold,  and  were 
ushered  in  by  spasm  of  the  peripheral 
arterioles,  which  presumably  produced 
the  cardiac  disturbance  because  of  the  in- 
creased exertion  demanded  of  the  heart 
in  order  to  propel  the  blood  through  nar- 


AXGIXA  PECTORIS.    PATHOLOGY. 


347 


rowed  channels.  Cases  of  this  sort  must 
be  rare.  Authors  quote  Nothnagel  with- 
out mentioning  similar  personal  observa- 
tions. 

From  a  neuralgia  or  a  neurosis  true 
angina  pectoris  differs  in  being  usually 
fatal,  in  attacking  men  ten  times  as 
often  as  women,  and  in  being  associated 
with  organic  changes  in  the  neighboring 
structures,  viz.:  the  heart  and  aorta. 

Lesions  of  the  cardiac  plexus  and  the 
branches  of  the  vagus  have  been  found 
in  repeated  instances  of  angina  pectoris, 
but  that  such  lesions  are  invariably  pres- 
ent and  essential  to  the  disorder  has  not 
yet  been  proved.  "The  cardiac  nerves 
may  be  seriously  implicated  in  aneurism, 
in  mediastinal  tumors,  in  adherent  peri- 
cardium, and  in  the  exudate  of  acute 
pericarditis,  without  causing  the  slight- 
est pain."    (Osier.) 

The  late  Sir  Benjamin  W.  Richardson 
regarded  angina  pectoris  as  an  actual 
disease  analogous  (as  Trousseau  held) 
to  epilepsy,  and  due  to  a  disturbance  in 
the  sympathetic  nervous  system. 

Debove  says  that  in  tabetic  angina 
pectoris  there  is  no  organic  lesion  of  the 
heart  or  large  vessels  and  that  the  at- 
tack must  be  regarded  as  a  visceral  crisis. 
Dana  refers  cardiac  crises  in  tabes  to  a 
degenerative  irritation  of  the  vagus. 

[It  should,  however,  be  remembered 
that  aortic  disease  is  rather  frequent  in 
tabetic  patients.    H.  F.  Vickbey.] 

In  regard  to  the  causation  of  attacks 
of  angina  pectoris  in  the  graver  cases 
which  are  associated  with  serious  struct- 
ural disease  of  the  heart  and  vessels,  J. 
Burney  Yeo  states  that  in  by  far  the 
greater  number  of  deaths  from  organic 
disease  of  the  heart  all  the  various  lesions 
may  be  present  which  have  been  found 
in  fatal  cases  of  angina  and  yet  no  true 
anginal  attacks  have  ever  been  com- 
plained of.    In  his  opinion  there  is  some 


additional  circumstance  needed  to  ac- 
count for  the  angina.  The  most  serious 
forms  of  angina  seem  to  have  a  complex 
causation.  First,  there  must  be  a  neu- 
rosal  element;  the  nerves  of  the  cardiac 
plexus  suffer  irritation,  and  an  intense 
cardiac  nerve-pain  is  excited;  this  acts 
as  a  shock  to  the  motor  nerves  of  the 
heart,  and  thus  reacts  on  the  heart-mus- 
cle, which,  in  fatal  cases,  is  already  on 
the  verge  of  failure  from  organic  causes; 
and,  if  there  should  be  excited  at  the 
same  time  some  reflex  arterial  spasm,  the 
heart  will  have  to  encounter  an  increased 
peripheral  resistance  as  well.  In  such 
cases  the  rapidity  of  the  fatal  issue  is  no 
argument  against  the  neuralgic  nature  of 
the  angina.  In  certain  conditions,  espe- 
cially in  habitual  high  arterial  tension, 
strain  is  apt  to  fall  (when  the  aortic 
valves  are  competent)  rather  on  the  first 
part  of  the  aorta  than  on  the  ventriciilar 
surface,  and  anginal  attacks  are  more 
prone  to  occur  in  these  cases,  as  this  part 
of  the  aorta  is  in  such  close  relation  with 
the  nerves  of  the  cardiac  plexus,  rather 
than  in  those  cases  in  which  the  strain 
is  felt  on  the  interior  of  the  cardiac  cavi- 
ties. The  causation  of  the  less  grave  and 
more  remediable  forms  of  angina  is  also, 
in  many  instances,  complex.  A  cardio- 
vascular system,  feeble  and  poorly  nour- 
ished, on  account  of  anemia,  may  be 
submitted  to  undue  strain;  or  there  may 
be  some  intoxication — such  as  that  of 
tea,  tobacco,  alcohol,  gout,  or  some  intes- 
tinal toxin — irritating  the  cardiac  and 
vasomotor  nerves,  increasing  peripheral 
resistance,  and  so  exciting  anginal  at- 
tacks, which  may  altogether  pass  away 
and  be  completely  recovered  from.  Va- 
somotor spasm,  as  a  unique  cause  of  at- 
tacks of  angina,  must  be  set  aside  as 
inconsistent  with  extended  clinical  ex- 
perience. Cases  of  angina  pectoris,  both 
of  the  milder  and  graver  forms,  occur 


348 


ANGINA  PECTORIS.    PROGNOSIS.    TREATMENT. 


without  any  evidence  of  vasomotor  spasm 
or  of  heightened  arterial  tension;    and 
the  conditions  of  heightened  arterial  ten- 
sion, together  with  a  feeble  cardiac  mus- 
cle, very  commonly  co-exist,  without  any 
tendency  whatever  to  the  development 
of   anginal   attacks.     The   argument   in 
favor  of  a  vasomotor  causation  has  been 
inferred    from    therapeutic    experiment 
and  the  relief  to  the  paroxysm  which  has 
attended  the  use  of  agents  which  cause 
arterial  relaxation.    But  most,  if  not  all, 
of  these  vasodilators  are  also  anesthetics, 
and,  as  Balfour  has  pointed  out,  it  is 
probably  to  their  anodyne  action  on  the 
sensory   cardiac   nerves   that   they   owe 
their  chief  eiiicacy;  Grainger  Stewart  has 
also  pointed  out  that  nitrite  of  amyl  has 
a  direct  effect  on  nervous  structures,  and 
that  it  relieves  other  forms  of  neuralgia. 
Angina  pectoris  is  due,  not  to  an  in- 
crease, but  to  a  further  reduction,  of  tlie 
muscular  energy  of  a  heart  already  en- 
feebled:   the  Stokes-Parry  theory.     The 
associated     pathological     processes     are 
sclerosis  of  the  coronary  vessels,  altera- 
tions  of  the   aortic  valves,   and   ectasic 
aortitis,  which  latter  has  a  special  stenotic 
effect  upon   the   origin   of  the  coronary 
vessels.     These  conditions,  together  with 
the  resistance  of  the  contracted  arterial 
system,  induce  weakening  of  the  heart. 
A  moderate  distension  of  the  heart  may 
lead   to   a   temporary    occlusion    of    the 
coronary  vessels  at  the  point  of  an  al- 
ready existing  constriction,  and  so  bring 
on    an    attack    of    angina   pectoris.      In 
other  cases  a  thrombus  or  embolus  may 
be   the   cause   of  the  block.     T.   Sehott 
(Lancet,  Sept.  8,  1900). 
Prognosis. — The  underlying  condition 
is  apt  to  prove  fatal  eventually,  and  it 
may  end  life  in  the  first  paroxysm;   but 
a  careful  regimen  may  prolong  existence 
for  years;  and  Flint,  Bendel,  and  Labol- 
bary  have  each  reported  cases  of  recovery. 
The  signs  of  danger  during  any  par- 
ticitlar  attack  are  the  subjective  sense  of 
impending  death  and  the  feebleness  and 


irregularity  of  the  pulse.  The  general 
prognosis  is,  of  course,  influenced  by 
the  stage  which  the  organic  circrilatory 
changes  have  already  reached. 

The  pseudo-attacks  are  apt  to  be  re- 
peated oftener  than  are  the  genuine,  but 
the  prognosis  is  good  both  as  to  life  and 
to  the  final  disappearance  of  the  trouble. 
True   angina,  when  it  occurs  in  dila- 
tation of  the  heart,  admits  of  a  prognosis 
more  favorable  than  when  it  occurs  with 
other   mural   conditions,   as   myocarditis 
or  hypertrophy,  without  dilatation. 

Grave  cases  of  dilatation  of  the  heart, 
conversely  to  the  above,  may  be  looked 
upon  as  amenable  to  successful  treat- 
ment if  the  patient  should  have  par- 
oxysms of  true  angina  pectoris.  J.  H. 
Musser  (Amer.  Jour,  of  Med.  Sciences, 
Sept.,  '97). 

The  majority  of  writers  hold  that  true 
angina  pectoris   (that  is,  combined  with 
anatomical  lesion  of  the  heart,  fatty  de- 
generation    sclerosis     of     the     coronary 
arteries,  etc.),  generally  ends  sooner  or 
later  in  sudden  death,  and  that  recovery 
is  a  rare  exception.     Personal  experience 
in   seventy-three   cases   has   shown   that 
this   statement  holds   good   only   of  pa- 
tients in  whom  angina  is  combined  with 
aortic   insufficiency.      Among   the    other 
eases  there  was  only  a  single  patient  who 
died    suddenly    after    the    disease    had 
lasted  tliree  years.     Most  of  them  after 
treatment  recovered  sufficiently  to  under- 
take laborious  work;    a  few  were  com- 
pletely  cured,   and   in   only   three   eases 
did  no  improvement  take  place.    Of  these 
one  was  a  drinker  and  a  great  smoker, 
another  suffered  from  pleurisy,  while  in 
the   third    arteriosclerosis    went    on    de- 
veloping,   aortic    insufficiency    was    pro- 
duced,  and   the   patient   died    suddenly. 
Fr.  Somberger  (Sbornik  Klinicky,  vol.  i, 
Fasc.  1,  '99). 
Treatment.  —  During  a  paroxysm  the 
first  remedies  to  employ  are  such  as  will 
dilate  the  arterioles.     Nitrite  of  amyl  is 
the  best  because  it  acts  with  the  greatest 
rapidity.    A  "pearl"  of  this  drug  may  be 
crushed  in  a  handkerchief  or  in  cotton 
placed  in  the  bottom  of  a  glass  tumbler, 


ANGINA  PECTORIS.    TREATJIEXT. 


349 


and    inhaled.       Nitroglycerin    may    be 
injected    subcutaneously    (^/loo    to    V50 
grain),  or  a  tablet  of  this  substance  may 
be  masticated.     It  is  readily  absorbed 
from    the    mouth    and    acts    almost    as 
quickly  as  when  given  hypodermicaUy. 
For  treatment  of  attack  itself,  rest,  the 
inhalation  of  5  or  6  drops  of  nitrite  of 
amyl  and  an  hypodermic  injection  of  '/loo 
grain  of  nitroglycerin  are  to  be  resorted 
to.    To  overcome  the  syncope  ether,  caf- 
feine, or  camphorated  oil,  the  latter  in 
10-per-cent.  strength,  are  to  be  employed. 
Friction  should   also   be   applied  to   the 
limbs  and,  should  there  be  evidences  of 
pulmonary  involvement,  venesection  must 
be  practiced,  while,  if  respiration  fails, 
rhythmical  tractions  of  the  tongue  must 
be  performed.    Fifteen-  to  45-grain  doses 
of  antipyrine  may  be  given  by  the  stom- 
ach   or   by   rectal    mjection,   or   smaller 
amounts  of  phenacetin  may  be  used;   to 
the  point  of  pain  chloride-of-ethyl  spray 
may  be  applied.     Lyon  (Revue  de  Ther. 
Med.-chir.;    Ther.  Gaz.,  Oct.  15,  "OS). 

In  angina  pectoris  pearls  of  amyl-nitrite 
recommended,  especially  in  the  beginning 
of  the  attack.  The  dose  is  from  5  to  10 
drops.  Should  the  attack  last  for  any 
length  of  time  injections  of  nitroglycerin 
advised.  A  good  formula  is  as  follows:  — 
1}  Spirit  of  nitroglycerin,  10  minims. 

Cherry-laurel  water,  3  drachms. 
M.     Twenty  minims  to  be  injected  sub- 
cutaneously. 

Small  blisters  to  the  prsecordium  are 
often  useful.     Between  attacks  the  diet 
should  be  very  limited  and  the  use  of 
alcohol  and  tobacco  be  forbidden.    Iodides 
should  be  given  for  at  least  from  two  to 
four  years  following  an  attack,  and  it  is 
well  to  alternate  the  sodium  and  potas- 
sium salts  and  combine  them  with  digi- 
talis or  caffeine.     Huguenin   (Allgemeine 
med.  Central-zeit.,  No.  14,  '98). 
Eelief  by   these   means  is   often   im- 
mediate;   but,  if  not,   ether  should  be 
inhaled.     Chloroform  is  also  advised  by 
excellent  authorities.    Flint  thinks  it  not 
without  danger,  if  the  heart  is  weak; 
ether,  on  the  other  hand,  is  a  stimulant. 
Morphine,  subcutaneoiisly,  is  a  valuable 


and  sometimes  an  indispensable  remedy. 
Whittaker  suggests  that  it  be  given  with 
caution  in  a  condition  which  may  any- 
way terminate  in  sudden  death.  The 
morphine  (V^  grain)  may  he  guarded  by 
atropine  (V150  grain),  and  in  case  of 
alarm  also  by  strychnine  (^/ao  to  V2» 
grain).  Electricity  has  also  been  recom- 
mended. 

Electricity  is  generally  unreliable  or 
dangerous,  and  faradization  should  be 
used  only  in  threatening  syncope. 
Huchard  (Univ.  Med.  Mag.,  May,  '92). 
The  application  of  the  continuous 
electric  current  along  the  course  of  the 
vagus  in  the  neck  and  down  the  arm, 
in  cases  where  a  distinctly  painful  aura 
is  experienced  in  the  hand,  has  been 
found  useful  in  warding  off  attacks. 
Burney  Yeo    (Practitioner,  May,  '93). 

Electricity  certainly  seems  to  exercise 
its  best  effects  in  those  cases  in  which 
the  pain  is  of  a  very  positive  neuralgic 
character,  with  no  co-existing  organic 
disease,  although  the  presence  of  struct- 
ural changes  in  the  heart  and  blood- 
vessels does  not  contra-indicate  the  judi- 
cious use  of  either  form  of  current. 
Rockwell  (Hare's  "System  of  Practical 
Therap.,"  vol.  i,  p.  394). 

.  Hot  and  stimulating  applications  over 
the  prseeordia,  such  as  a  strong  mustard 
poultice,  are  appropriate,  as  are  also  heat 
and  friction  for  the  extremities.  Some- 
times an  ice-bag  is  put  over  the  heart. 
Alcohol  and  aromatic  spirit  of  ammonia 
are  of  benefit  in  case  the  cardiac  action 
is  feeble.  Syncope  demands  such  drugs 
as  digitalis,  digitaline,  caffeine,  strych- 
nine, and  camphor,  employed  hypoder- 
micaUy. I  have  known  oxygen  to  con- 
tribute to  a  favorable  result  in  collapse 
due  to  chronic  myocarditis  with  dilata- 
tion of  the  left  ventricle,  and  cannot  see 
why  it  might  not  be  well  for  a  subject 
of  angina  pectoris  to  keep  some  ready 
in  his  house. 

Between  attacks  it  is  of  vital  impor- 
tance to  avoid  the  predisposing  and  ex- 


350 


ANGINA  PECTORIS.     TREATMENT. 


citing  causes.  Best  and  moderation  are 
demanded.  As  for  drugs,  nitroglycerin, 
taken  after  meals  in  doses  just  short  of 
causing  headache,  has  a  distinct  inhibi- 
tory effect  upon  the  paroxysms.  In  some 
instances  it  might  be  better  to  order  it 
every  three  hours,  as  its  influence  is  not 
long  continued.  Nitrite  of  sodium  (2  to 
5  grains)  may  replace  nitroglycerin. 

A  new  remedy  is  erythrol-tetranitrate 
in  grain  doses  four  times  in  the  twenty- 
four  hours.  If  this  drug  is  given  in 
spirit  and  water  (1  grain  in  1  drachm 
of  alcohol  and  7  drachms  of  water)  the 
tension  begins  to  fall  in  two  or  three 
minutes;  if  given  in  a  pill,  the  time  is 
twenty  to  forty  minutes;  if  given  in 
tabloid  form  and  chewed,  the  time  lies 
somewhere  between  the  two.  The  drug 
was  not  introduced  to  replace  amyl- 
nitrite  and  nitroglycerin  in  cutting  short 
attacks,  but  only  to  replace  them  in  pre- 
venting the  onset  of  the  attacks.  J.  B. 
Bradbury  thinks  the  tablet  imdoubtedly 
the  best  form  of  administration. 

Severe  case  in  a  physician,  in  which 
erythrol-tetranitrate  (1-grain  closes)  was 
taken  steadily,  at  eight  hours'  interval, 
as  a  prophylactic.  For  three  weeks 
there  was  immunity  from  attacks,  al- 
though some  weariness  and  oppression 
came  on  after  six  or  seven  hours  from 
taking  the  tablets.  Now  taken  four 
times  in  the  twenty-four  hours  with 
marked  relief. 

The  initial  fall  of  the  pulse-tension  de- 
pends on  the  mode  of  administration.  If 
the  drug  is  given  in  spirit  and  water 
(1  grain  in  1  drachm  of  alcohol  and  7 
drachms  of  water)  the  tension  begins  to 
fall  in  from  two  to  three  minutes;  if 
given  in  a  pill  and  swallowed,  the  time 
is  from  twenty  to  forty  minutes;  if 
taken  in  tablet  form  and  masticated  the 
time  lies  somewhere  between  the  two. 
The  best  form  of  administration  is  un- 
doubtedly the  tablet.  The  alcoholic  solu- 
tion sometimes  irritates  the  stomach. 
Bradbury  (Brit.  Med.  .Jour.,  Apr.  10, '97). 


Erythrol-tetranitrate  in  angina  pec- 
toris. Case  in  which  glycerin  soon  lost 
its  effect,  and  its  administration  was 
attended  by  severe  headaches.  Erythrol- 
tetranitrate  was  substituted  in  tablets  of 
Vo  grain,  each,  two  to  three  times  a  day. 
This  produced  a  cessation  of  the  attacks, 
tlie  administration  of  the  remedy  being 
attended  by  the  same  vasodilator  effect 
noted  in  the  use  of  the  nitrites  and 
glonoin,  but  the  action  was  much  more 
sustained.  Houghton  Addy  (Brit.  Med. 
Jour.,  May  6,  '99). 

The  persistent  use  of  potassic  iodide  is 
very  effective.  Ten  or  15  grains  may  be 
given  thrice  daily  before  meals  in  half  a 
glass  of  water;  or  20  grains  three  times 
a  day  for  twenty  days,  followed  by  nitro- 
glycerin for  ten  days.  The  iodide  is  be- 
lieved to  dilate  the  arterioles  and  to  pro- 
mote arterial  nutrition.  See  supposed 
that  also  by  enlarging  the  calibre  of  the 
coronary  arteries  it  invigorated  the  myo- 
cardium. 

Arsenic  in  small  doses  also  tends  to 
avert  the  paroxysms.  In  case  of  fatty 
degeneration  of  the  heart  it  would  be 
contra-indicated. 

Quinine  and  methylene-blue  have  also 
been  recommended. 

The  treatment  by  saline  baths  and  by 
the  Schott  method  of  exercises  has  a 
most  potent  effect  in  improving  the  con- 
dition of  the  cardiac  muscle  and  vessels, 
and  appears  to  have  a  direct  effect  in 
making  the  attacks  less  numerous  and 
severe,  and  even  in  causing  them  to 
cease  during  a  period  of  months  or  years. 
The  movements  must  be  made  with  es- 
pecial care  and  caution  in  these  cases, 
and  the  resistance  at  the  onset  must  be 
at  a  minimum.  The  artificial  saline 
baths  should  contain  from  1  to  3  per 
cent,  of  salt,  and  from  V4  to  1  per  cent, 
of  chloride  of  calcium,  and  should  grad- 
ually be  strengthened  by  the  addition  of 
carbonic  acid.     (H.  N.  Heineman.) 


AXGINA  PECTORIS.    TREATMENT. 


351 


Angina  jjectoi'is  "with  pseudcsteno- 
crtidia.  The  angina  is  due  to  probable 
endo-aortitis,  and  is  relieved  by  an  ex- 
clusive milk  diet  and  theobromine  for 
two  weeks.  Then,  one  week  every 
month,  milk  diet  and  sodium  iodide. 
During  the  balance  of  the  month,  spe- 
cial diet,  with  the  theobromine  con- 
tinued. H.  Huchard  (Jour,  des  Prati- 
ciens,  Feb.  23,  1901). 

The  writer  confirms  the  remarkable 
benefit  to  be  derived  from  theobromine 
in  these  conditions  as  announced  by 
Askanazy  in  1895.  The  diuretic  influ- 
ence of  this  drug  is  familiar,  but  its 
property  of  promptly  arresting  the 
pains  of  angina  pectoris,  cardial  asthma, 
and  allied  conditions  is  less  generally 
known,  and  yet  the  writer  considers  it 
one  of  the  most  blessed  facts  in  modern 
therapeutics.  He  describes  over  a  dozen 
cases  in  detail,  showing  its  rapidly 
beneficial  influence  in  all  pains  of  arte- 
rial origin.  They  form  a  series  rang- 
ing from  pure  angina  pectoris  to  attacks 
of  pain  attributed  by  the  patients  to 
the  head,  stomach,  shoulder,  kidney,  or 
intestines,  and  apparently  with  no  feat- 
ures in  common  with  angina  pectoris ; 
yet  all  show  by  the  prompt  response 
to  theobromine  that  they  have  a  com- 
mon origin  in  the  arteries  and  that 
theobromine  has  a  specific  action  on  the 
latter.  Arteriosclerosis  and  certain 
other  affections  of  the  arteries  are  li- 
able to  cause  constant  pains  in  the  ves- 
sels which  may  radiate  to  remote  re- 
gions. The  pains  may  be  due  to  in- 
creased blood-pressure  and  distension, 
but  they  are  also  liable  to  be  caused 
by  spasmodic  contraction  of  the  ar- 
teries. These  contractions  occur  by 
preference  in  the  smaller  arteries  and 
are  the  result  of  pathological  or  path- 
ologically exaggerated  reflexes  originat- 
ing in  the  diseased  vascular  wall.  They 
are  set  in  motion  by  various  causes 
which  raise  the  blood-pressure,  emotions, 
muscular  exertion,  the  horizontal  posi- 
tion in  sleeping,  etc.  They  are  especially 
liable  to  occur  in  the  organs  which  re- 
quire the  largest  supply  of  arterial 
blood,  such  as  the  digestive  tract,  heart, 
and  muscles.  The  arterial  fluxion  in- 
duced by  increased  function  starts  the 
attack  of  pain.     The  spasmodic  contrac- 


tion of  the  arteries  causes  symptoms 
of  ischtemia  as  the  arterial  supply  is  cut 
ofl'  from  muscular  organs.  In  the  ex- 
tremities it  becomes  evident  as  inter- 
mittent claudication;  in  the  digestive 
tract  as  paresis  and  meteorism;  in  the 
heart,  as  sudden  inadequacj'  and  paral- 
ysis. Sensory  phenomena  may  be  super- 
added to  these  and  it  becomes  diflioult 
to  decide  whether  the  pains  are  due 
to  the  vascular  spasm  or  to  the  ischse- 
mie  parenchyma.  When  the  vessels  of 
the  heart  are  directly  or  indirectly  in- 
volved the  specific  angor  cordis  devel- 
ops. The  lesions  of  the  heart  arteries 
may  radiate  the  pain  to  remote  regions. 
The  spasm  of  the  heart  arteries  is 
peculiarly  intense  when  it  is  not  the 
result  of  the  usual  causes,  but  is  due 
to  direct  irritation  of  the  intima  by  a 
thrombus  or  embolus.  This  explains 
the  sudden  death  that  may  occur  from 
a  small  embolus  in  one  of  the  terminal 
ramifications  of  a  coronary,  as  well  os 
in  case  of  obstruction  of  a  large  artery 
from  this  cause.  Theobromine  has  evi- 
dently some  action  on  the  spasmodic 
contraction  of  the  arteries,  and  when 
this  is  controlled  the  pain  ceases.  It 
may  also  act  by  diminishing  the  refle.x 
excitability  or  by  reducing  the  arterial 
pressure.  Be  this  as  it  may,  the  fact 
is  established  that  theobromine  is  a 
powerful  and  harmless  remedy  for  pain* 
on  an  arterial  basis.  The  writer  always 
gave  it  in  the  form  of  diuretin  (Elnoll), 
in  doses  of  0.5  gramme  four  or  five 
times  a  day,  and  in  the  severest  cases 
3  to  4  grammes  a  day.  The  only  ob- 
jection to  its  use  is  the  high  price 
charged  for  the  preparations  of  theo- 
bromine. R.  Breuer  (Miinchener  med. 
Woch.,  Oct.  14,  1902;  Jour.  Amer.  Med. 
Assoc,  Nov.  15,  1902). 

The  cardiac  tonics — sparteine,  stro- 
phanthus,  strychnine,  valerian,  and  in 
suitable  cases  digitalis — are  of  the  great- 
est utility. 

Digitalis  is  of  doubtful  utility.  It 
should  not  be  given  unless  there  is  an 
excess  of  dilatation.  J.  H.  Musser 
(Amer.  Jour.  Med.  Sciences,  Sept.,  '97). 

The  general  tendency  to  anaemia  and 
defective  oxygenation  must  never  be  lost 


352 


ANGINA  PECTORIS. 


ANIIALONIUM  LEWINII. 


sight  of,  and  general  tonics,  including 
the  use  of  oxygen-gas,  will  be  of  excellent 
service. 

Angina  pectoris  is  due  to  a  simple 
liyperaemia  of  the  spinal  sensory  centres. 
A  spinal  ice-bag  from  the  fourth  dorsal 
to  the  third  lumbar  vertebra,  applied 
once  or  twice  a  day  for  from  forty  min- 
utes to  an  hour,  will  not  only  relieve  the 
attacks,  but  will  completely  eradicate 
the  trouble.  Amyl-nitrite  is  useful.  An- 
other remedy  recommended  very  highly 
is  oxygen  by  inhalation.  Oxygen  alone 
will  relieve  an  attack  of  angina,  but  in 
combination  with  cold  over  the  spine  and 
heat  to  the  extremities  it  is  the  speediest 
method  of  relief  at  our  command.  Most 
efficient  formula  of  oxygen  for  adminis- 
tration consists  of  2  parts  of  pure 
oxygen,  1  part  nitrous  monoxide,  and  1 
per  cent,  of  ozone.  B.  Kinnear  (Med. 
Record,  July  16,  'OS). 

Attacks    of    pseudo-angina    may    be 
treated     with     asafoetida,     ammoniated 
tincture  of  valerian,  or  compound  spirit 
of  ether,  and  the  outward  employment 
of  heat-friction  and  rubefacients.    Some- 
times recourse   must  be   had,   however 
reluctantly,  to  morphine.    The  statement 
in  clear  and  decided  language  of  a  favor- 
able prognostic  prospect  is  of  great  bene- 
fit.   Between  attacks  the  underlying  con- 
dition should  be  cared  for.    (Heineman.) 
The  fact  of  the  pain  itself  being  capa- 
ble   of   acting   as   a   vasoconstrictor   has 
been    too    much    overlooked.      Certainly 
morphine  is  the  great  remedy  that  we 
have    usually   to   fall   back   upon   when 
vasodilators  have  spent  their  powers  of 
affording  relief.     Graham   Steell    ("The 
Sphygmograph  in  Clinical  Medicine,"  '99; 
Phila.  Med.  Jour.,  Feb.  24,   1900). 

Herman  F.  Vickeht, 

Boston. 

ANHALONIUM  LEWINII  (MESCAL 
BUTTON).  — The  mescal  button  is  ob- 
tained from  a  plant  which  grows  in  a 
valley  of  the  Eio  Grande,  in  Mexico. 
The  tops  of  the  plant  when  dried  consti- 
tute the  commercial  form  of  Anlialonium 


Lewinii,  first  described  by  Lewin.  They 
are  brownish  in  color,  circular,  and  from 
one  to  one  and  a  half  inches  in  diameter. 
The  button  is  hard  and  can  be  pulverized 
in  the  mortar  with  difficulty.  In  the 
mouth,  however,  under  the  action  of  the 
saliva,  it  swells  and  rapidly  becomes  soft, 
giving  a  nauseous  and  bitter  taste,  with 
a  marked  sensation  of  tingling  in  the 
fauces.  An  alkaloid  (anhalonine)  has 
been  extracted  from  anhalonium.  It  is  a 
glucoside,  with  an  action  somewhat  like 
that  of  strychnine,  and  is  very  poisonous. 

Dose." — The  following  preparations 
may  be  used:  A  tincture  (10  per  cent.). 
Dose,  1  to  3  teaspoonfuls.  An  extract 
of  leaves  (100  per  cent.).  Dose,  7  ^/^  to 
15  minims.  Powdered  leaves,  7  ^/g  to  15 
grains.  The  tincture  and  extract  should 
be  made  according  to  the  processes  pre- 
scribed in  the  United  States  Pharma- 
copoeia for  such  preparations. 

Physiological  Action.  —  Lewin  found 
anhalonium  to  be  an  intensely  poisonous 
drug,  and  that  a  few  drops  of  a  decoc- 
tion used  by  him  in  the  frog  sufficed 
to  produce  almost  instantly  very  marked 
changes,  chiefly  consisting  in  the  appear- 
ance of  skrinking  of  the  body,  so  that 
the  batrachian  seemed  to  pass  into  a 
mummified  condition.  Simultaneously 
with  these  appearances,  the  animal  raised 
itself  iipon  its  fore-extremities  and  re- 
mained standing  in  this  position  like  an 
ordinary  quadruped,  or  crawled  about. 
After  fifteen  minutes  this  spastic  condi- 
tion passed  off  and  he  rapidly  returned 
to  his  normal  condition.  When  larger 
amounts  were  given,  death  occurred  in 
tetanic  rigidity.  It  would  seem  that  the 
symptoms  produced  by  it  are  closely 
allied  to  those  of  strychnia,  for  Lewin 
noted  that  even  after  the  spinal  cord 
was  severed  peripheral  irritation  caused 
tetanus.  On  pigeons  it  was  found  that 
the  drug  produced  convulsive  vomiting 


ANHALONIUM  LEWINII.     THERAPEUTICS. 


353 


in  a  few  moments  when  given  hypoder- 
mieally.  The  bird  spread  its  wings, 
crouched  down  to  the  ground,  and  if 
disturbed  would  twitch  convulsively. 
Later  the  head  was  drawn  sharply  back, 
the  mouth  opened  widely,  and  general 
convulsions  asserted  themselves.  When 
death  occurred  the  heart  was  always 
found  in  diastole.  In  rabbits  the  symp- 
toms were  those  of  strychnia  poison.  The 
taste  of  the  liquid  preparations  is  some- 
what disagreeable,  unless  it  be  disguised 
by  a  suitable  vehicle,  such  as  a  mixture 
of  fluid  extract  of  licorice  and  elixir  of 
yerba  santa.  The  powdered  drug  is  best 
administered  in  wafer-paper,  cachets,  or 
capsules.    (Lewin.) 

It  seems  to  produce  an  effect  in  the 
human  subject  resembling  that  of  Indian 
hemp:  visions  ranging  from  flashes  of 
color  to  beautiful  landscapes,  figures,  etc. 
It  depresses  the  muscular  system  without 
having,  however,  produced  intoxication, 
as  would  be  the  case  with  alcohol.  An- 
halonium  is  not  hypnotic  and  sometimes 
induces  wakefulness. 

The  principal  feature  of  the  visions  is 
the  eolor-eflfeot.  Tlie  power  of  the  drug 
seemed  to  be  mainly  due  to  the  develop- 
ment of  these  entrancing  visions.  Pren- 
tiss and  Morgan  (Ther.  Gaz.,  Sept.  15, 
'95). 

Personal  experience  in  the  use  of  the 
drug.  The  principal  phenomena  were 
extraordinary  color-visions,  and  also 
brilliant  form-illusions.  After-effects  of 
the  drug  quite  unpleasant,  producing 
nausea  and  headache  for  several  hours 
afterward.  Symptoms  produced  resem- 
bling the  visual  phenomena  of  ophthal- 
mic migraine,  suggesting  that  possibly 
the  drug  might  be  found  useful  in  this 
affection.  S.  Weir  Mitchell  (Jour.  Nerv- 
ous and  Mental  Dis.,  Sept.,  '9fl). 

The  important  effect  of  the  alkaloid  of 
the  mescal  plant  in  therapeutic  doses 
would  appear  to  be:  1.  A  direct  stimula- 
tion of  the  intracardiac  ganglia.  2.  An 
initial  slowing  of  the  heart.  ?,.  An  ele- 
vation of  arterial  tension.     4.   A  direct 

1- 


stimulation  of  the  brain-centres  and 
motor-centres  of  the  cord,  as  shown  by 
the  increase  in  reflex  excitability.  Dixon 
{Brit.  Med.  Jour.,  Oct.  8,  '98). 

Investigations  carried  out  on  writer 
himself  were  made  to  determine  the 
active  ingredient  producing  the  peculiar 
visual  hallucinations  described  by  Pren- 
tiss and  Morgan,  Weir  Mitchell,  and 
others.  In  the  first  place,  an  alcoholic 
extract  of  mescal  buttons  corresponding 
to  4V2  drachms  was  taken,  and  after- 
ward an  amount  of  the  individual  alka- 
loids corresponding  to  the  quantity  in 
the  extract.  The  active  ingredient  was 
found  to  be  mescaline.  The  symptoms 
produced,  both  by  the  alcoholic  extract 
and  mescaline  {IV:  grains),  were  colored 
visual  hallucinations,  slowing  of  the 
pulse,  dilatation  of  the  pupil,  loss  of 
time-relations,  heaviness  of  the  limbs, 
nausea,  and  headache.  After  anhaloni- 
dine  (1 '/,  to  3  Vi  grains)  some  sleepiness 
and  heaviness  of  the  head  were  observed, 
but  no  visions  or  change  in  the  pulse. 
Anhalonine  (IV2  grains)  only  produced 
slight  sleepiness,  while  lophophorine 
(^%oo  grain)  induced  a  painful  feeling  at 
the  back  of  the  head  and  burning  and 
redness  of  the  face.  The  pulse  fell  from 
78  to  70  per  minute,  but  all  the  symp- 
toms were  transient.  After  a  resin  ob- 
tained from  the  plant  no  visions  or  other 
typical  symptoms,  except  heaviness  of 
the  limbs,  were  obtained;  thus  the  theory 
that  this  is  the  active  ingredient  is  dis- 
posed of.  Heffter  (Arehiv  f.  Exp.  Path, 
u.  Pharm.,  xl,  385,  '98). 

Anhalonium,  in  drop  doses,  a  sustainer 
of  the  respiration  and  a  cardiac  stimu- 
lant. Seminal  emissions  may  occur  from 
"its  use  without  erection.  A  valuable  ad- 
juvant to  digitalis,  according  to  Landry. 

Therapeutics. — The  use  of  mescal  but- 
tons is  credited  with  beneficial  results  in 
general  "nervousness,"  nervous  headache, 
nervous  irritable  cough,  abdominal  pain 
due  to  colic  or  griping  of  the  intestine, 
hysterical  manifestations,  and  in  other 
similar  afEections  where  an  antispasmodic 
is  indicated;  as  a  cerebral  stimulant  in 
depressed  conditions  of  the  mind, — hypo- 


35-t 


ANIMAL  EXTRACTS.     THYROID.     PHYSIOLOGICAL  ACTION. 


chondriasis,  melancholia,  and  allied  con- 
ditions; as  a  substitute  for  opium  and 
chloral  in  conditions  of  great  nervous 
irritability  or  restlessness,  active  delirium 
and  mania,  and  in  insomnia  caused  by 
pain,  in  color-blindness. 

ANIMAL  EXTRACTS.  —  Under  this 
heading  are  included  not  only  the  ex- 
tracts of  various  tissues  at  present  util- 
ized in  therapeutics,  but,  likewise,  the 
tissues  themselves,  and  all  the  prepara- 
tions, active  principles,  etc.,  that  are 
obtained  from  them. 

Of  the  animal  tissues,  and  the  products 
obtained  from  them,  employed  therapeu- 
tically, the  ductless  glands,  whose  func- 
tions are  now  known  to  be  intimately 
associated  with  metabolism,  have  by  far 
taken  the  lead  over  all  other  portions  of 
the  animal  organism  utilized.  Indeed, 
if  they  continue  to  increasingly  engage 
attention  as  they  have  of  late,  the  time 
is  not  far  ofE  when  antitoxins  will  find 
in  them  a  potent  rival.  On  this  account, 
considerable  space  has  been  devoted  to 
the  subject  as  a  whole;  but,  as  the  pre- 
vailing views  still  belong  to  the  domain 
of  conjecture,  the  purpose  of  this  article 
vnll  be  to  present  what  evidence  clini- 
cians have  furnished. 

Our  personal  views  will  only  be  in- 
corporated in  this  article  after  the  pro- 
fession at  large  will  have  recognized  their 
merit,  if  such  exist.  This  work  is  only 
intended  to  portray  generally-accepted 
doctrines. 

The  ductless  glands  and  their  prepa- 
rations will  first  be  considered  in  the  cr- 
der  of  their  importance  in  therapeutics. 
A  few  pages  will  then  be  devoted  to 
the  various  other  organs  and  products 
at  present  being  tried,  the  so-called 
"organic  extracts,"  some  of  which  are 
rapidly  losing  their  claim  to  recognition. 


Thyroid  Gland. 

In  the  latter  part  of  the  last  century. 
King,  of  London,  showed  experimentally 
that  the  colloid  substance  of  the  thyroid 
gland  passed  directly  into  the  lymphat- 
ics; and  Schiff,  in  1859,  reviving  views 
previously  held  by  many,  showed  that 
this  organ  played  an  important  part  in 
the  economy,  through  some  substance 
which  it  secreted,  and  that  intraperi- 
toneal transplantation  of  the  healthy 
gland  in  a  dog  shortly  after  thyroidec- 
tomy had  been  performed  prevented 
cachexia  strumipriva,  which  follows  this 
operation.  Then  followed,  in  18S3,  the 
experiments  of  Kocher  and  Reverdin, 
demonstrating  that,  in  man  as  well  as  in 
animals,  the  same  phenomena  occurred 
under  identical  circumstances.  This  led 
the  way  to  the  investigations  of  Murray 
and  Ord,  who,  followed  by  many  observ- 
ers, then  showed  that  myxcedema  could 
be  counteracted  by  the  internal  adminis- 
tration of  thyroid  gland.  Since  then  this 
organ  has  been  used  as  a  remedy  in  a 
large  number  of  disorders  and  with 
marked  success  in  some,  the  best  results 
being  obtained  in  conditions  more  or  less 
distinctly  associated  with  myxcedema. 

Physiological  Action. — Under  the  in- 
fluence of  a  preparation  of  thyroid  gland 
the  body-weight  diminishes  and  the  ex- 
cretion of  nitrogen,  water,  carbonic  acid, 
sodium  chloride,  and  phosphoric  acid 
increases,  indicating  a  decided  influence 
upon  general  metabolism. 

Increased  metabolism,  shown  by  (1) 
elevation  of  temperature;  (2)  increased 
appetite,  with  more  complete  absorption 
of  nitrogenous  foods;  (3)  loss  of  weight, 
with  nitrogen  excreted  in  excess  of  that 
taken  in  the  food;  (4)  growth  of  skele- 
ton in  the  very  young;  (5)  marked  im- 
provement in  body -nutrition  generally; 
(6)  increased  activity  of  mucous  mem- 
branes, skin,  and  kidneys.  The  rheu- 
matic symptoms  and  the  anaemia  are  not 


ANIMAL  EXTRACTS.    THYROID.    PHYSIOLOGICAL  ACTION. 


355 


only  not  relievedj  but  are  frequently 
aggravated.  G.  W.  Crary  (Amer.  Jour. 
Med.  Sciences,  May,  '94). 

Appearance  of  glycosuria  as  a  result 
of  the  administration  of  tablets  of  thy- 
roid gland.  Ewald  (La  Sera.  Med.,  p. 
357,  '94). 

Metabolism  during  thj-roid  treatment 
studied  in  three  goitrous  patients,  aged, 
respectively,  19,  24,  and  27  years,  their 
usual  diet  being  given.  1.  The  goitre 
diminished  in  size  in  all  the  cases.  2. 
The  body-weight  decreased  one  kilo- 
gramme in  one  case,  and  two  kilo- 
grammes in  the  other  two  cases.  The 
diminution  in  \\eight  depended  on  the 
duration  of  the  treatment.  3.  The 
amount  of  urine  was  increased.  4.  The 
nitrogenous  excretion  appeared  to  be 
increased,  chiefly  through  the  urine.  5. 
The  increase  in  nitrogenous  excretion 
caused  a  negative  nitrogenous  balance 
of  5.46,  5.2,  and  4.34,  respectively.  6. 
The  uric-acid  excretion  was  increased 
in  two  of  the  cases  examined.  7.  The 
excretion  of  solid  chloride  and  phosphoric 
acid  was  increased.  The  considerable 
increase  in  phosphoric-acid  metabolism, 
mentioned  by  Eoos,  not  confirmed,  but 
only  phosphoric  acid  in  the  urine,  and 
not  in  the  faeces,  was  estimated.  Irsai, 
Vas,  and  Gara  (Deutsche  med.  Woch., 
July  9,  '96). 

Experiments  to  ascertain  whether  the 
loss  of  the  weight  takes  place  at  the 
expense  of  the  fat  of  the  body  or  of  the 
protoplasmic  tissues,  such  as  the  muscles. 
Conclusions:  that  fresh  thyroid  acts  en- 
ergetically on  albuminous  decomposition, 
but  that  some  of  the  eflSciency  is  lost  to 
the  thyroid  substance  in  the  process  of 
making  tablets  or  in  keeping  it  too  long. 
The  administration  of  the  artificial  prod- 
ucts over  long  periods  of  time  is,  how- 
ever, not  without  action  on  albuminous 
substances.  Gluzinski  and  Lemberger 
(Centralb.  f.  inn.  Med.,  Jan.  30,  '97). 

Under  the  effect  of  thyroid  there  is  an 
increased  rapidity  of  combustion  through- 
out the  body,  while  the  increased  urinary 
flow  which  follows  its  use  decreases  the 
patient's  weight  considerably  as  well. 
Another  important  effect  of  the  thyroid 
gland  is  to  hasten  cell-activity.     Robert 


Hutchinson    (Brit.  Med.  Jour.,  July   16, 
■98). 

Following  conclusions  deducted  from  a 
series  of  investigations  on  thyroid  treat- 
ment: 1.  The  loss  of  weight  after  the 
ingestion  of  thyroid  is  not  due  con- 
clusively to  loss  of  water  and  albumin, 
but  in  part,  in  some  cases,  to  loss  of 
fat.  Thyroid  causes,  therefore,  a  genu- 
ine reduction  of  fat.  2.  So  far  as  this  is 
due  to  increase  of  normal  tissue-change 
it  is  moderate,  except  in  my.xoedema.  3. 
Increase  of  metabolism  does  not  occur  in 
all  persons  who  take  thyroid.  It  is  most 
marked  in  myxoedema.  4.  The  proteid 
deficit  in  thyroid  feeding  may  continue 
even  in  case  of  superalimentation,  and 
is,  therefore,  a  specific,  toxicogenic  effect 
of  the  substance.  5.  Thyroidin  shows 
efi'ects  on  metabolism  like  those  of  the 
extract  of  the  glands,  but  thyreotoxin 
and  potassium  iodide  give  no  such  re- 
sults. 6.  Absence  of  thyroid  function 
causes  not  only  defective  growth  and 
serious  bodily  and  psychical  degeneration, 
but  also  a  distinct  decrease  of  gaseous 
interchange,  of  heat-production,  and  of 
total  metabolism.  The  excessive  and  ab- 
normal function  causes  increased  metab- 
olism and  emaciation.  Administration  oi 
the  gland  in  such  cases  is  followed  by  in- 
creased metabolism  and  improvement  of 
symptoms.  7.  The  loss  of  fat  and  albu- 
min in  thyroid  feeding  shows  a  plain 
analogy  with  the  same  process  in  Base- 
dow's disease  and  is  toxic  when  it  reaches 
a  high  grade.  Thyroid  preparations 
must,  therefore,  be  used  cautiously  in  the 
treatment  of  obesity.  A.  Magnus  Levy 
(Zeit.  f.  klin.  Med.,  B.  33,  p.  258,  '98). 

In  rabbits  thyroid  substance  produced 
a  lowering  of  the  blood-pressure,  begin- 
ning a  few  seconds  after  the  injection 
and  persisting,  with  an  unchanged  heart- 
action.  The  fall  in  pressure  is  due  to 
dilatation  of  the  vessels.  As  substances 
having  a  similar  action  are  found  in  the 
hypophysis  extract  and  adrenal  extract, 
and  since,  moreover,  peptones  have  the 
same  influence,  no  final  conclusions  can 
be  drawn  from  the  action  of  the  thyroid 
extract  upon  the  tone  of  the  vessels. 
Bela  V.  Fenyvessy  (Wiener  klin.  Woch., 
Feb.  8,  1900). 


356 


ANIMAL  EXTRACTS.     THYROID.     PHYSIOLOGICAL  ACTION. 


It  seems  exceedingly  probable  that 
the  iTntoward  phenomena  resulting  from 
thyroid  extirpation  are  due  to  an  in- 
toxication, to  some  kind  of  an  autoin- 
fection,  whose  harmful  influence  is  no 
longer  counteracted  by  the  normal  ac- 
tion of  the  thyroid  gland.  The  efEect 
of  thyroid  transplantation  or  implanta- 
tion, together  with  the  positive  results 
produced  by  thyroid  feeding  or  by  the 
use  of  extracts,  speaks  for  the  action  of 
the  gland  by  means  of  a  secretion, — that 
is,  at  ,a  distance  from  the  gland;  and 
this  is  against  the  view  that  some  have 
suggested,  that  the  toxic  substances  are 
brought  to  the  gland  and  there  trans- 
formed or  rendered  innocuous.  The 
gland  acts,  therefore,  not  by  virtue  of 
storage  or  of  direct  blood  purification. 
(J.  W.  Warren.) 

Substances  which  diminish  the  excita- 
bility of  the  nervous  system,  bromide  of 
potassium  and  antipyrine  in  particular, 
will  diminish  or  suppress  the  convul- 
sive symptoms  following  thyroidectomy. 
Gley   (La  Sem.  Med.,  Apr.  13,  '92). 

In  dogs  the  symptoms  of  tetanus 
caused  by  thyroidectomy  can  be  over- 
come by  large  doses  of  potassium  bro- 
mide. Fifty  dogs  thus  kept  alive  two 
years  and  two  six  years  after  the  opera- 
tion. Same  results  obtained  with  hypo- 
dermic injections  of  a  concentrated  solu- 
tion of  the  substance  of  the  thyroid 
gland,  and  with  a  solution  of  the  gray 
matter  of  the  brain  of  healthy  dogs. 
Canizzaro  (Deutsche  med.  Woch.,  No. 
184,  '92). 

Intravenous  injections  of  solutions  of 
brain,  testicle,  or  blood-serum  have  no 
such  effects  as  the  thyroid  juice.  Ex- 
periments favoring  the  belief  that  the 
thyroid  gland  has  the  function  of  pre- 
venting autointoxication,  by  transform- 
ing the  toxic  products  of  tissue-change 
into  substances  easily  eliminated,  or  by 
directly  neutralizing  them  by  its  own 
secretion.  Vassale  (Review  of  Insanity 
and  Nervous  Dis.,  June,  '92) . 

In  Bright's  disease  two  to  six  thyroid 


glands  of  the  sheep  per  week  increase 
the  density  of  the  urine  and  the  quantity 
of  urea  is  augmented  very  sensibly.  Gif- 
ford  (Brit.  Med.  Jour.,  Mar.  31,  '94). 

Study  of  sixty  cases.  The  action  of 
thyroid  extract  is  complex.  It  undoubt- 
edly produces  a  mild,  feverish  condition, 
the  action  and  reaction  of  which  are 
often  of  considerable  benefit.  It  is  a 
direct  cerebral  stimulant.  There  is  a 
strong  probability  that  at  some  periods 
of  life  the  administration  of  the  thyroid 
supplies  some  substance  necessai"y  to  the 
bodily  economy.  Bruce  (Jour,  of  Mental 
Science,  Oct.,  '94). 

Experiments  on  dogs  showing  that 
after  removal  of  the  thyroid  the  urotoxic 
coefficient  rose  to  nearly  double.  The 
toxicity  of  the  blood-serum  also  increased 
after  thyroidectomy.  The  thyro-iodine 
of  Baumann,  when  given  to  athyroidized 
dogs,  caused  the  urotoxic  coefficient  to 
return  almost  to  the  normal,  and  re- 
lieved most  of  the  nervous  symptoms. 
Spoto  (Gior.  dell  Assoc,  di  Napoli,  p. 
526,  '96). 

Five  mice  and  three  guinea-pigs  were 
treated  with  thyroid  extract.  Swelling 
of  the  face,  emaciation,  and  loss  of 
strength.  In  all  cases  the  administra- 
tion was  continued  till  the  animal  died. 
No  lesion  found  of  either  nerve-elements 
or  neuroglia;  no  varicose  or  atrophied 
dendrites  or  loss  of  gemmulae.  The  cor- 
pora showed  no  loss  of  angularity,  and 
the  axons  and  appendages  were  all 
healthy.  No  nuclear  change  in  the  cells 
ascertained;  the  blood-vessels  were  care- 
fully examined  without  the  discovery  of 
any  lesion.  It  would  seem  from  these 
investigations,  so  far  as  they  go,  that  the 
toxic  action  of  thyroid  is  of  a  different 
nature  from  that  of  other  conditions,  and 
one  which  we  are  not,  therefore,  in  a 
position  to  understand.  Berkley  (Bulle- 
tin of  the  Johns  Hopkins  Hospital,  July, 
'97). 

Two  main  hypotheses  have  been  ad- 
vanced as  to  how  the  secretion  of  the 
thyroid  acts  on  the  tissue  of  the  body: 
First,  that  the  tissue  forms  toxic  sub- 
stances which  are  neutralized  by  the  thy- 
roid secretion;  this  is  the  antitoxic 
theorv.     Second,  that  the  thyroid  secre- 


ANIJL4.L  EXTRACTS.     THYROID.     ACTIVE  PRINCIPLES. 


357 


tion  promotes  or  regulates  normal  metab- 
olism; this  is  the  trophic  hypothesis. 
All  the  newer  evidence  seems  to  point  to 
the  latter  as  the  more  probable  one.  H. 
Sneve  (Columbus  Med.  Jour.,  Dee.  20, 
'98). 

The  thyroid  gland  is  not  to  be  re- 
garded as  an  organ  pouring  a  useful  in- 
ternal secretion  into  the  circulation;  the 
lymph  leaving  it,  and  the  lymphatic 
glands  in  the  vicinity,  do  not  contain 
iodine;  and  the  blood  and  central  nerv- 
ous system  in  healthj'  animals  are  also 
free  from  iodine.  Removal  of  the  thyroid 
is  followed  by  disease  and  death,  because 
the  organ  which  removes  poisonous  sub- 
stances from  the  blood  can  no  longer  pro- 
tect the  animal.  It  is  the  central  nervous 
system  which  principally  suilers,  and  by 
Nissl's  method  great  changes  (ehroma- 
tolysis)  can  be  demonstrated  in  the 
ganglion-cells.  The  thyroid,  therefore, 
appears  to  be  the  great  protective  organ 
to  the  central  nervous  system.  The 
poisonous  substances  are  destroyed  by 
oxidation,  and  this  appears  to  be  assisted 
by  combinations  with  the  iodine.  F. 
Blum  (Pflueger's  Archiv,  70,  '99). 

Iodine-holding  proteid  compounds  are 
almost  wholly  separable  from  the  gland 
by  water.  The  total  iodine  of  the  gland 
is  so  distributed  that  about  96  per  cent, 
can  be  separated  by  alcohol,  acids,  etc., 
as  iodo-albumin  compounds  in  firmly 
bound  form.  Thyroidin  does  not  occur 
free  in  the  gland.  R.  Tambach  (Zeit. 
f.  Biol.,  xxxvi,  No.  4.  p.  549,  '99). 

Removal  of  the  thyroid  alone  invari- 
ably causes  myxedema,  W'hile  removal 
of  the  fonr  parathyroids  produces  the 
acute  tetanic  symptoms  observed  after 
so-called  experimental  "thyroidectomy." 
The  partial  tetany  sometimes  observed 
after  apparent  removal  of  the  thyroid 
in  man  is  most  likely  really  due  to  the 
inadvertent  removal  of  some  of  the 
parathyroids  along  with  the  thyroid 
proper.  The  symptoms  of  myxcedema 
can  be  fully  explained  by  the  absence  of 
iodothyrin  from  the  blood  which  such 
removal  entails,  and  the  symptoms  of 
parathyroidectomy  are  not  yet  sus- 
ceptible of  any  satisfactory  explana- 
tion. Robert  Hutchison  (Practitioner 
Apr.,  1901). 


Active  Principles  of  Thyroid.  —  It  is 

quite  clear  that  the  thjToid  gland  is  es- 
pecially characterized  by  the  presence  of 
a  compound  proteid  of  peculiar  consti- 
tution, and  that  this  substance,  which 
Eobert  Hutchinson  calls  "colloid  matter," 
is  the  active  constituent  of  the  gland 
There  is  also  present  another  proteid,  a 
nucleo-albumin,  in  small  amount,  which 
Hutchinson  considers  as  probably  con- 
tained in  the  cells  of  the  acini.  In 
addition  there  are  certain  extractives  to 
be  found, — viz.,  xanthin,  hypoxanthin, 
inosite,  volatile  fatty  acids,  paralactic 
acid,  succinic  acid,  and  calcium  oxalate, 
— bodies,  however,  of  no  special  physio- 
logical significance.  (E.  H.  Chittenden.) 
Iodine  has  recently  been  shown  by 
Baumann  to  be  a  normal  constituent 
of  the  thyroid  gland.  Thyro-iodine — 
the  name  given  by  him  to  the  product 
obtained — contains  over  9  per  cent,  of 
iodine,  and  it  becomes  inert  when  the 
latter  agent  is  removed  from  it.  Bau- 
mann has  also  shown  that  the  amount 
of  iodine  in  the  gland  is  much  greater 
when  the  organ  is  normal  than  when  it 
is  goitrous. 

Thyro-iodine  is  best  prepared  by  treat- 
ing the  gland  with  a  solution  of  sodium 
chloride.  The  globulin  is  precipitated  by 
a  current  of  carbonic  acid,  and  the  solu- 
tion acidified  and  boiled,  when  a  pre- 
cipitate of  albumin  and  thyro-iodine 
falls.  The  latter  is  an  organic  substance 
combined  with  nitrogen  and  iodine  (10 
per  cent.).  Clinical  observations  show 
that  thyro-iodine  is  very  active,  patients 
suffering  from  goitre  and  myxcedema 
having  been  cured  by  it.  Baumann  main- 
tains that  the  entire  active  substance  re- 
mains on  the  filter  after  coagulation  of 
the  albumin.  Baumann  (Zeit.  f.  physiol. 
Chem.,  B.  21,  pp.  319  and  481,  '96). 

The  colloid  material,  believed  by 
Hiitchinson  to  be  the  active  ingredient 
of  the  thyroid  gland,  has  been  found  to 
contain  iodine  in  organic  combination, 


358 


ANIMAL  EXTRACTS.     THYROID.     PREPARATIONS. 


the  colloid  matter  owing  its  activity  to 
the  presence  of  this  organic  compound 
of  iodine. 

The  proteids  of  the  gland  are  two  in 
number:  1.  A  nueleo-albumin  pi-esent 
in  small  amount  and  probably  derived 
from  the  cells  lining  the  acini.  2.  The 
colloid  matter,  made  up  of  a  proteid  and 
a  non-proteid  part,  the  latter  containing, 
in  all  probability,  Baumann's  throidin. 
Certain  extractives  are  also  obtained 
from  the  gland,  as  creatin,  xanthin,  etc., 
which  have  been  found  absolutely  inert 
when  administered  either  to  healthy 
persons  or  to  cases  of  myxcedema.  The 
same  result  obtained  on  giving  the  nu- 
eleo-albumin. The  pure  colloid  matter 
gave  the  ordinary  signs  of  thyroid  ac- 
tivity in  healthy  individuals,  and  in 
large  doses  distinct  thyroidism  resulted. 
Marked  beneficial  results  were  obtained 
on  administering  it  to  a  patient  with 
myxcedema.  The  proteid  and  the  non- 
proteid  constituents  of  the  colloid  were 
then  given  separately,  and  although 
benefit  resulted  from  the  former,  yet  the 
most  favorable  results  were  obtained 
from  the  administration  of  the  latter. 
Robert  Hutchinson  (Brit.  Med.  Jour., 
Jan.  23,  '97). 

The  colloid  substance  is  the  active  se- 
cretion of  the  thyroid  gland,  and  is  made 
up  of  thyreoglobulin  and  nucleoproteid. 
Experiments  were  undertaken  to  show 
the  influence  which  thyreoglobulin  and 
mucleoproteid  exercised  upon  general 
metabolism.  Results  showed  that  in  the 
■case  of  dogs  the  excretion  of  nitrogen 
Avas  considerably  increased  when  thyreo- 
globulin was  given,  whereas  nucleopro- 
teid had  no  efTect  upon  the  output  of 
nitrogen. 

Thyreoglobulin  is  the  most  active  body 
in  the  thyroid  gland;  it  contains  all  the 
iodine,  and  the  amount  of  iodine  in- 
creases pari  passu  with  the  increased  col- 
loid material;  it  therefore  follows  that 
thyreoglobulin  is  contained  in  the  col- 
loid material.  Oswald  (Hoppe-Seyler's 
Zeit.  f.  physiol.  Chemie,  vol.  xxvii.  Parts 
1  and  2,  '99). 

Thyro-antitoxin     is    the     provisional 
name   of   another   active   principle,    ob- 


tained by  Fraenkel,  from  the  thyroid 
gland  of  the  sheep.  It  exerts  no  influ- 
ence on  nutrition  comparable  with  that 
of  fresh  thyroid  or  thyro-iodine. 

The  albuminous  bodies  were  precipi- 
tated by  acetic  acid,  and  by  feeding  ex- 
periments it  was  ascertained  that  the 
precipitate  had  no  marked  effect,  while 
the  filtrate  that  was  obtained  possessed 
the  well-known  properties  of  the  thyroid 
gland,  or,  in  other  words,  contained  the 
physiological  active  principle.  Fraenkel 
(Wiener  med.  Bl.,  S.  48,  '95). 

In  the  tetanic  condition  toxins  are 
found  in  the  blood  which  are  rendered 
innocuous  by  the  thyro-antitoxin  of 
Fraenkel,  formed  in  the  gland-alveoli.  In 
the  myxoedeniatous  condition,  on  the  con- 
trary, a  "thyroproteid"  is  formed  in  the 
tissues,  passes  into  the  blood,  and  is 
fixed  by  the  thyroid.  Here  it  is  ren- 
dered innocuous  by  an  enzyme  which 
splits  it  up  into  two  parts:  a  proteid 
constituent,  which  unites  with  thyro- 
iodine,  and  the  other  a  carbohydrate. 
Notkin  (Virchow's  Archiv,  Suppl.,  B. 
144,  '96) . 

Preparations,  —  The  implantation  of 
a  portion  of  the  thyroid  gland  beneath 
the  skin  was  soon  superseded  by  the  hypo- 
dermic method,  bitt  the  latter  presented 
another  drawback,  that  of  requiring  the 
constant  attendance  of  the  physician. 
Besides  this  the  preparations  often  pro- 
duced suppuration.  The  gland  itself, 
therefore,  administered  in  the  form  of 
desiccated  powder  in  tablets  or  capsules, 
is  preferred  by  the  majority  of  practi- 
tioners. 

It  seems  evident,  all  in  all,  that   the 
entirely  unobjectionable  whole  gland  pre- 
pared in  desiccated  powder  or  capsule  or 
in  compressed  tablet  is  the  only  means 
by  which  we  ought  to  attempt  to  treat 
conditions    in    which    this    animal    sub- 
stance has  been  found  useful.     Editorial 
(Ther.   Gaz.,  May  15,  '97). 
The  glands  of  young  sheep  have  given 
the  best  results.    When  the  glands  them- 
selves are  to  be  administered,  considerable 


ANIMAL  EXTRACTS.     THYROID.     PREPARATIONS. 


359 


care  should  be  taken,  and  they  should  be 
obtained  through  a  veterinary  surgeon. 
Again,  the  glands  should  be  carefully 
examined  to  ascertain  that  they  are  not 
diseased. 

Over  50  per  cent,  of  sheep's  thyroids 
e.xamined  showed  more  or  less  evident 
indications  of  deviation  from  the  normal. 
Emphasis  on  the  need  of  care  in  the 
selection  of  glands  for  administration. 
A.  Napier  (London  Lancet,  Feb.  4,  '93). 
It  is  usually  advisable  for  the  doctor 
himself  to  get  the  thyroid  lobes.  If  it 
is  left  to  the  butcher  quite  other  sub- 
stances may  be  supplied.  The  glands  of 
sheep,  and.  especially  of  young  sheep,  are 
to  be  preferred,  tuberculosis  being  ex- 
tremely rare  in  this  animal.  The  sheep 
has  two  thyroid  bodies,  one  on  each  side 
of  the  trachea.  The  upper  part  of  each 
thyroid  corresponds  exactly  to  the  track 
of  the  butcher's  knife  in  bleeding  the 
animal;  the  top  of  the  gland  is  almost 
always  cut  by  the  knife,  and  this  forms 
a  good  guiding  mark  for  finding  the 
gland  at  once.  Gabriel  Gauthier  (Lyon 
Mgd.,  June  27,  July  11,  '97). 

The  thyroids  should  be  removed  as 
quickly  as  possible  after  the  animal  is 
killed.  After  careful  antiseptic  prepara- 
tion of  the  field  of  operation,  the  glands 
should  be  dissected  out  with  aseptic  in- 
struments, and  after  removing  all  the 
fat  and  connective  tissue  they  should 
be  put  into  a  sterilized,  covered  glass 
dish  which  has  been  previously  weighed. 
The  organs,  as  soon  as  secured,  should 
also  be  taken  to  the  laboratory  and 
weighed.  They  are  then  cut  into  small 
pieces  with  aseptic  scissors  and  double 
their  weight  is  added  of  a  mixture  con- 
taining 2  parts  of  glycerin  and  1  part  of 
sterilized  water.  After  standing  in  this 
for  twenty-four  hours,  they  are  poured 
into  a  suitable  bottle,  which  is  stoppered 
with  cotton  and  sterilized.  The  extract 
thus  obtained  is  poured  into  small  ster- 
ilized bottles  and  will  keep  for  a  consid- 
erable time. 


Of  the  extracts  containing  20  per  cent, 
of  the  thyroid  gland,  1  drachm  per  week 
may  be  given,  and  of  the  thyroid  glands 
themselves  1  lobe:  that  is,  one-half  of 
the  entire  gland.  The  latter  may  be 
administered  chopped  finely  and  cooked, 
or  it  may  be  macerated  after  chopping 
in  a  small  quantity  of  water,  and  the 
extract  thus  obtained  given  in  beef-tea 
without  cooking.  Broiled  slightly,  the 
natural  juices  of  the  thyroid  are  less 
altered  when  administered. 

A  powder  may  be  made  by  separating 
the  gland  from  all  foreign  tissues  and, 
after  chopping  finely,  desiccating  at  a 
low  temperature  to  avoid  cooking.  The 
objection  to  this  method  is  that  the 
powder  has  an  unpleasant  odor,  which, 
however,  may  be  disguised  by  mixing 
with  cacao  and  administering  in  pill 
form;  8  pills,  of  ^/^  of  a  grain  each, 
are  given  daily.  This  amount  is  nearly 
equivalent  to  one  lobe  of  the  thyroid. 
This  powder  may  also  be  dispensed  in 
tablets  or  inclosed  in  gelatin  capsules. 

If  small  quantities  have  to  be  admin- 
istered, owing  to  antagonism  on  the  part 
of  the  patient,  etc.,  Murray's  method 
may  be  used.  The  gland  is  cut  into 
small  pieces,  and  macerated  in  an  equal 
amount  of  glycerin,  the  extract  being 
obtained  by  pressure  and  filtration  and 
administered  in  drop  doses.  The  dose  is 
four  times  that  employed  in  hypodermic 
medication. 

The  action  of  the  thyroid  gland  is  to 
convert  the  salts  of  iodine,  which  are 
present  in  the  blood,  into  iodothyrin.  It 
would  therefore  seem  advantageous  to 
administer  iodothyrin  in  place  of  thyroid 
extracts.  De  Cyon  (Med.  News,  Oct.  1, 
'98). 

Aiodine  is  a  new  preparation  obtained 
by  precipitating  with  tannin  the  iodo- 
albuminates:  the  bases  and  the  mucous 
substance  of  the  thyroid  gland.  Fifteen 
grains  of  aiodine  correspond  to  one  hun- 


360 


ANIMAL  EXTRACTS.    THYROID.     UNTOWARD  EFFECTS. 


dred  and  fifty  grains  of  fresh,  or  three 
hundred  grains  of  desiccated,  thyroid 
gland.  Schoerges  (Nouveaux  Remedes, 
Aug.  24,  '98). 

New  preparation,  aiden,  a  precipitate 
from  a  solution  of  thyroid  in  normal 
salt  by  means  of  tannin.  It  contains  a 
greater  number  of  the  extractive  prin- 
ciples of  the  gland  than  have  hitherto 
been  obtained,  as  shown  by  experiments 
on  animals.  Jaquet  (Correspondenz- 
blatt  f.  Sehweizer  Aerzte;  Med.  News, 
June  10,  '99). 

The  fresh  gland  furnishes  20  per  cent, 
of  extract  or  27  to  28  per  cent,  of  dry 
powder.  The  powder  is  employed  in 
tablet  form,  in  the  dose  of  Ve  of  a  grain. 

A  powder  that  will  keep  for  a  long 
time  may  be  prepared  in  the  following 
manner:  After  an  aseptic  removal  of 
the  glands,  and  removing  all  foreign  tis- 
sues, pulpify  and  mix  them  with  the 
bibcrate  of  soda  and  powdered  charcoal. 
In  this  manner  is  obtained  a  dry  powder, 
which  is  put  in  capsules,  each  contain- 
ing 1  Vs  grains  of  the  extract.  This 
preparation,  when  not  exposed  to  heat, 
is  not  altered.  Vigier  (Archives  de 
Neurol.,  Mar.,  '96). 

A  preparation  that  will  also  keep  a 
long  time  is  the  following:  Immediately 
after  the  death  of  the  animal  the  gland  is 
excised  under  all  aseptic  precautions,  all 
extraneous  tissues  are  removed,  and  the 
gland  is  powdered  with  boric  acid.  When 
a  sufficient  number  have  been  prepared 
they  are  taken  to  the  laboratory,  cut  up, 
and  triturated  with  sugar  and  an  addi- 
tional amount  of  boric  acid.  The  sugar 
absorbs  the  juices,  and  the  resulting 
mixture  is  almost  free  from  liquid.  This 
mixture  is  desiccated  at  a  temperature  of 
86°  C,  and  divided  into  small  masses, 
which  are  coated  with  gelatin,  each  mass 
containing  about  1  ^/j  grains. 

Each  lobe  of  the  thyroid  produces 
about  26.8  per  cent,  of  powder;  three 
capsules  are  therefore  equivalent  to  one 


lobe  of  the  gland,  or  the  therapeutic 
unit.    (Yvon.) 

The  thyroid  extracts  prepared  by  the 
pharmaceutical  chemists  of  the  United 
States  offer  a  convenient  form  of  admin- 
istration. 

TJntoward  Effects  and  their  Preven- 
tion.— The  dangers  attending  the  use  of 
thyroid  preparations  depend,  to  a  degree, 
upon  the  manner  in  which  the  remedy 
is  administered.  When  the  pure  gland 
is  used,  the  j)hysiological  phenomena 
caused  by  an  overdose  will  show  them- 
selves,— namely:  a  weak,  rapid  pulse  and 
shortness  of  breath;  vomiting,  cardiac 
oppression,  a  feeling  of  tightness  around 
the  chest,  vertigo,  and  coma.  When 
dried  powder  or  compressed  tablets  are 
used  symptoms  of  ptomaine  poisoning 
may  be  added  to  those  mentioned. 

Too  great  an  increase  in  the  pulse-rate 
and  vomiting  are  signs  that  the  patient 
is  getting  too  much.  H.  W.  G.  Macken- 
zie (Centralb.  f.  Nerv.  Psy.,  July,  '93). 

In  giving  thyroid  preparations,  the 
best  guide  is  the  pulse.  Any  consider- 
able quickening  or  palpitation  should 
lead  us  to  discontinue  the  drug  until 
the  cardiac  action  is  again  normal. 
There  are  no  dangers  in  the  use  of  the 
drug,  provided  we  begin  with  small 
doses,  from  1  to  2  grains  of  Ameri- 
can extracts,  and  gradually  increase, 
watching  the  pulse.  It  should  never  be 
given  to  a  patient  who  cannot  be  closely 
watched.  R.  C.  Cabot  (Med.  News, 
Sept.  12,  '96). 

Case  in  which  a  man  took  for  obesity 
nearly  1000  5-grain  tablets  of  thyroid 
extract  within  five  weeks.  After  the 
first  three  weeks  he  began  rapidly  to 
develop  the  symptoms  of  acute  Graves's 
disease.  When  thyroid  was  stopped  and 
patient  was  put  upon  arsenic  all  the 
symptoms  disappeared  quickly,  excepting 
the  eye  changes  and  the  goitre,  which 
were  still  notable  for  about  six  months. 
A.  V.  Notthaft  (Centralb.  f.  innere  Med., 
Apr.  16,  '98). 


ANIMAL  EXTRACTS.    THYKOID.     UNTOWARD  EFFECTS. 


361 


Among  the  less  active  symptoms  are 
anorexia,  diarrhoea,  malaise,  lassitude, 
and  pain  in  the  extremities;  headache, 
increase  of  urine,  rise  of  temperature, 
various  eruptions,  urticaria,  transient 
and  papular  erythema  and  eczema,  and, 
in  some  eases,  nervous  manifestations: 
neuralgia,  delirium,  convulsions,  delir- 
ixim  of  persecution,  aphasia,  monoplegia, 
etc. 

Some  of  the  discomforts  of  treatment 
are  a  feeling  of  tightness  in  the  chest, 
with  itching,  burning,  and  otlier  ab- 
normal sensations  in  the  skin,  and  a 
sense  of  Aveakness.  G.  Stewart  (Practi- 
tioner, July,  '93). 

Thyroid  powder,  when  given  subeu- 
taneously,  also  produces  a  rise  of  tem- 
perature. It  is  a  pyrogenic  agent.  This 
action  of  the  thyroid  shows  that  we 
should  be  careful  in  its  administration 
to  persons  affected  with  heart  disease. 
Isaac  Ott  (Med.  Bull.,  Oct.,  '97). 

The  drug  is  badly  tolerated  by  general 
paralytic  and  tuberculous  patients,  still 
worse  by  patients  over  60  years  of  age, 
and  worst  of  all  by  fat  patients,  espe- 
cially those  in  whom  there  is  reason  to 
suspect  fatty  degeneration  of  the  heart. 
C.  C.  Easterbrook  (Lancet,  Aug.  27,  '98). 

Among  the  early  warnings  obtainable 
when  large  doses  are  being  administered 
is  undue  loss  of  weight. 

Loss  of  weight  is  an  early  sign  of  im- 
provement, which  sometimes  goes  beyond 
the  requirements  of  health.  Rise  of  tem- 
perature and  pulse,  increase  of  urine, 
faintness,  headache,  prostration,  cardiac 
weakness,  and  neuralgic  pains  have  been 
observed  during  treatment.  J.  J.  Put- 
nam  (Amer.  Jour.  Med.  Sci.,  Aug.,  '93). 

It  is  a  powerful  remedy,  and  must  be 
used  with  caution.  A  daily  dose  or  one 
every  second  day  may  be  sufficient. 
One-half  to  1  grain  to  children  and  5  to 
10  grains  to  adults  personally  given. 
J.  H.  Musser  (Inter.  Med.  Mag.,  Nov., 
1900). 

When  the  preparation  of  thyroid  first 
employed  tends  to  give  rise  to  untoward 


effects,  a  change  of  preparation  is  some- 
times suffi-cient. 

Case  in  which  the  glycerin  extract  of 
thyroid  could  not  be  taken,  even  in 
small  doseSj  without  the  production  of 
very  distressing  symptoms,  while  the 
powdered  extract  was  well  borne.  J.  M. 
Anders  (Med.  News,  June  12,  '97). 

If  even  then  the  preparations  are  not 
borne,  portions  of  the  gland  or  glandular 
extract  may  be  administered  by  the  rec- 
tum. The  extract,  as  shown  by  Lepine, 
can  also  be  injected  into  the  rectum. 

According  to  Mackenzie,  inunctions  of 
a  thyroidin  ointment  prepared  as  shown 
below  may  be  employed. 

When  patients  cannot  bear  even  very 
small  doses  of  thyroid,  twice  a  day,  after 
hot  sponging  and  vigorous  rubbing,  the 
body  is  well  anointed  with  the  following 
mixture: — • 

B  Thyroidin,  10  parts. 
Ether,  60  parts. 
Lanolin,  480  parts. — M. 

A  rise  of  temperature  of  one  degree 
followed  the  Inunction.  The  process  was 
well  borne  and  followed  by  satisfactory 
results.  E.  Blake  (Prov.  Med.  Jour., 
Sept,  1,  '94). 

Arsenical  preparations  antagonize  thy- 
roidal intoxication  through  the  energetic 
restraining  influences  of  arsenic  upon 
oxidation  processes.  They  diminish  the 
palpitation  of  the  heart  without  in  any 
Avay  interfering  with  the  other  good  in- 
fluences of  the  thyroid  gland.  Experi- 
ments upon  dogs  and  rabbits  to  which 
were  administered  thyroid  gland  and 
Fowler's  solution  and  several  cases 
showed  that  it  was  possible  to  push 
the  thyroid  gland  in  ascending  doses 
more  rapidly  and  with  better  effect  when 
arsenic  was  given  than  without  it.  Ma- 
bille  (Les  Nouveaux  Remedes,  May  8, 
'99). 

Mabille's  observation  confirmed  that 
arsenic  obviates  the  unpleasant  symptom 
excited  by  thyroid  preparations.  In  5 
cases  of  idiopathic  goitre,  in  a  case  of 
obesity,  and  1  of  infantile  myxoedema, 
iodothyrin  was  given  in  progressive  doses 


362 


ANIMAL  EXTRACTS.    THYROID.     UNTOWARD  EFFECTS. 


of  from  3  Vb  to  30  or  38  V2  grains  daily. 
At  the  same  time  arsenic  was  given, 
either  in  pills  or  as  Fowler's  solution,  in 
doses  increasing  proportionately  to  the 
iodothyrin  of  Voi  to  Vio  or  even  Vs  grain 
daily.  The  results  fully  confirmed  Ma- 
bille's  experience,  for,  though  the  7  cases 
took  respectively  231,  111,  86,  320,  108, 
296,  and  125  iodothyrin  tabloids,  con- 
taining nearly  4  grains  each,  beyond  oc- 
casional increased  frequency  of  the  pulse 
no  symptoms  of  thyroidism  appeared,  so 
that  the  course  could  be  continued  unin- 
terruptedly. Arsenic,  therefore,  appears 
to  suppress  thyroidism  with  greater  cer- 
tainty than  atropine  does  iodism,  and  it 
is  now  possible  to  giv'e  iodothyrin  safely 
in  doses  and  for  a  period  capable  of 
producing  definite  therapeutic  effects. 
Ewald  (Die  Therapie  der  Gegenwart, 
Sept.,  '99,  and  Med.  Review,  Dec,  '99). 

As  noted  in  cases  treated  by  Stabel, 
thyroid  gland  is  likely  to  canse  gastric 
disturbance  most  frequently  during 
warm  weather.  He  found  that  this 
could  be  avoided  by  preserving  the 
glands  or  their  preparations  on  ice, 
when  th€y  were  not  to  be  used  at  once. 

According  to  Lanz,  the  danger  con- 
sists more  in  the  extreme  alterability  of 
the  products  than  in  the  toxicity  of  their 
active  principles.  A  series  of  experi- 
ments showed  that  9  grains  of  the 
English  thyroidin,  dried  by  the  ordinary 
procedures,  gave  rise  to  tachycardia, 
whereas  the  absorption  of  from  5 
drachms  to  1  ounce  of  raw  fresh  thy- 
roid gland  did  not  give  rise  to  any 
disturbance.  Examination  of  pastilles, 
tablets,  tabloids,  capsules,  etc.,  revealed 
bacteria,  including  even  the  septic  vib- 
rio, ptomaines,  etc. 

Gastric  digestion,  as  shown  by  Howitz, 
in  no  way  modifies  the  properties  of 
the  glands.  Maurange  has  obtained  a 
peptone  which  can  be  kept  indefinitely 
either  in  the  dry  state  or  in  a  syrupy 
condition  with  the  addition  of  an  equal 
quantity  of  glycerin  and  alcohol.    It  may 


be  given  in  wine  or  sweetmeats  contain- 
ing 50  per  cent,  of  sugar.  The  author 
has  used  these  peptones,  named  by  him 
peptothyroidin,  peptovarin,  peptomedul- 
lin,  etc.,  for  fifteen  months  and  though 
still  very  imperfect  and  prepared  only  as 
needed,  they  have  been  perfectly  tole- 
rated even  by  confirmed  dyspeptics. 

As  to  the  use  of  any  of  the  active 
principles  described,  clinical  results  have 
not  sufficiently  sustained  the  theoretical 
views  concerning  their  actual  worth  to 
warrant  a  wholesale  recommendation  of 
them.  Again,  physiological  investiga- 
tions have  seemed  to  suggest  that  their 
influence  upon  general  metabolism  is  dif- 
ferent from  that  exercised  by  the  com- 
plete gland.  Still,  in  a  few  instances, 
excellent  results  have  been  obtained  from 
them  and  further  study  will  doubtless 
make  it  possible  to  isolate  an  active  prin- 
ciple devoid  of  useless  and  perhaps  harm- 
ful elements.  For  the  present,  therefore, 
the  gland  itself  or  prepared  in  desiccated 
powder  or  capsule  or  in  compressed  tab- 
let should  only  be  employed. 

A  promising  agent  is  Eobert  Hutch- 
inson's colloid.  Here,  however,  the  in- 
ert extractives  removed  are  mere  foreign 
bodies,  the  colloid  itself  being  a  compos- 
ite proteid  containing  various  active  ele- 
ments, including,  probabl_y,  Baumann's 
thyroidin.  We  are  not  dealing,  there- 
fore, with  an  active  principle  per  se,  but, 
in  reality,  with  the  active  part  of  the 
gland.  The  advantages  claimed  for  col- 
loid are:  1.  A  constancy  of  dose  is  in- 
sured. The  quantity  of  colloid  in  differ- 
ent glands  varies  considerably;  hence 
the  amount  of  active  substance  in  dried 
preparations  of  the  whole  gland  is  really 
not  constant.  2.  The  drug  is  quite  pure. 
3.  The  pure  colloid  is  free  from  taste 
and  odor,  and  keeps  indefinitely.  4.  A 
very  small  dose  is  required.  5.  The  col- 
loid is  absorbed  with  great  ease  and  ra- 


ANIJIAL  EXTRACTS.     THYROID.     THERAPEUTICS. 


363 


pidity.    6.  The  administration  of  the  col-  \ 
loid  matter  is  really  the  most  economical 
way  of  giving  the  thyroid.     There  is  no 
waste  of  active  material,  as  occurs  in  the 
preparations  of  thyroidin. 

Therapeutics. — The  diseases  in  which 
thyroid  gland  and  its  preparations  are 
utilized  are  so  numerous  that  a  general 
review  of  the  results  obtained  would  af- 
ford hut  little  information.  The  various 
disorders,  including  the  clinical  data 
collated  upon  each,  are  therefore  pre- 
sented separately,  and  in  alphabetical 
order. 

The  thyroid  extract  is  a  powerful  al- 
terative. Its  use  is  likely  to  be  of 
service,  however,  only  in  those  diseases 
which  are  in  some  way  related  to  par- 
tial or  total  suspension  of  the  thyroid 
function.  Its  action  is  almost  specific 
in  mj'xoedema,  sporadic  cretinism,  and 
the  cachexia  which  follows  the  e.xtirpa- 
tion  of  the  thyroid  gland.  Its  use  in 
insanity  is  in  some  degree  justified 
rationally  on  the  ground  that  in  that 
disease  altered  glandular  action  and 
disordered  metabolism  are  almost  uni- 
versally found. 

Thyroid  is  a  constant  ingredient  in 
antifat  remedies,  and  M.  Porges  has 
made  extensive  experimentation  in  this 
regard.  He  finds  that  the  majority  of 
eases  show  no  improvement  whatever, 
while  the  few,  and  those  are  those 
cases  which  readily  show  the  physiolog- 
ical action  of  the  remedy,  experience 
some  benefit.  He  thinks  that  in  these 
cases  the  fatness,  in  some  measure  at 
least,  is  due  to  the  defective  action  of 
the  thyroid  gland,  and  hence  the  ex- 
hibition of  the  thyroid  extract  is  highly 
rational.  On  the  whole,  he  condemns 
its  use  in  this  class  of  patients,  as  the 
benefits  derived  are  not  worth  the  haz- 
ard undergone  while  taking  the  treat- 
ment. 

It  has  been  tried  in  many  forms  of 
skin  diseases,  both  internally  and  as  a 
local  application.  The  results  reported 
are  variable.  Scleroderma,  psoriasis, 
eczema,  and  ichthyosis  are  said  to  do 
well  occasionalh',  and  of  late  very  en- 
couraging reports  of  it  have  been  noted 


in  st'ubborn  eases  of  diffuse  eczema. 
Externally,  it  has  been  tried  in  various 
forms  of  chronic  ulcer,  but  the  reports 
of  results  have  not  been  such  as  to 
show  that  it  had  any  special  value  for 
this  purpose.  De  Lace  reports  a  case 
of  severe  purpura  in  which  thyroid 
eft'ected  a  complete  cure. 

As  an  emmenagogue  it  has  repeatedly 
succeeded  when  other  means  had  failed, 
but,  when  given  for  this  purpose  solely, 
it  seems  to  be  useless.     In  cases  of  in- 
sanity   where    the    menstrual    function 
was    in    abeyance,    when    the    remedy 
ameliorated  the  patient's  general  mental 
and   physical   condition,   return   of   the 
menses  was  among  the   other  signs   of 
improvement,  but  in  no  case  was  men- 
struation   re-established    as    the     only 
apparent  result  of  the  treatment.      In 
exophthalmic   goitre,   with    or   without 
mental  symptoms,  it  seems  to  be  posi- 
tively harmful.     Hiram  Elliott  (Brook- 
lyn Med.  Jour.,  April,  1901). 
Arrested   Growth.  • —  In  the  treat- 
ment  of   dwarfing   thyroid  extract  has 
been  found  to  be  of  great  value,  whether 
the  condition  be  associated  with  idiocy 
or  not.    The  observations  of  Virchow,  in 
1883 — to  the  effect  that  rachitis,  cretin- 
ism, and  dwarfing  were  dependent  upon 
disease  of  the  thyroid  gland,  fully  sup- 
ported by  experiments  showing  that  thy- 
roid  feeding  was   capable   of  restoring 
normal  growth  when  the  latter  had  been 
arrested  by  thyroidectomy — pointed  dis- 
tinctly to  thyroid  as  a  valuable  remedial 
agent.     More   recent  experiments  have 
further  sustained  this  view  and  shown 
that  the  leanness  attending  rapid  growth 
in  yoitths  could  be  attributed  to  an  ex- 
aggerated activity  of  the  thyroid  gland. 
Effect    of    thyroid    in    children    and 
youths  who,  although  not  cretins,  were 
backward  in  growth.     In  6  of  these  cases, 
in  which  the  arrest  of  growth  was  due 
either  to  chronic  albuminuria  (2),  rickets 
(2),  masturbation  (1),  or  congenital  de- 
bility ( 1 ) ,  there  was  a  renewal  of  active 
growth, — in  some  very  considerable.     E. 
Hertoghe    (Bull,    de   I'Acad.   Royale    de 
Med.  de  Belgique,  '9.5). 


364 


ANIMAL  EXTKACTS.     THYROID.     CRETINISM. 


In  three  cases  of  myxcedematous  idiots, 
aged  from  14  to  30  years,  the  striking 
points  were  growth  and  a  loss  of  weight. 
In  three  other  cases  of  obesity  in  idiots 
the  growth  under  treatment  was  pro- 
portionately more  in  four,  five,  or  six 
months  than  the  average  growth  of  the 
eigliteen  untreated  imbeciles  or  epileptics 
during  their  tenth,  eleventh,  and  twelfth 
years,  which  were  taken  as  more  nearly 
approaching  normal  children  to  control 
these  experiments.  Bourneville  (Progres 
M«d.,  Feb.  1,  '96). 

The  rate  and  amount  of  the  increase 
in  height  is  in  inverse  ratio  to  the  age 
of  the  patient  and  to  the  stage  of  the 
treatment.  Thus,  children  grow  more 
than  adolescents,  and  adolescents  more 
than  adults;  the  rate  of  growth  is  at 
first  very  rapid,  but  becomes  slower  as 
the  height  approaches  that  of  the  nor- 
mal for  the  age.  John  Thomson  (Brit. 
Med.  Jour.,  ii,  615,  '96). 

Number  of  recorded  examples  of  dwarf- 
ing associated  with  atrophy  of  the  thy- 
roid gland  cited.  Experiments  on  ani- 
mals corroborate  the  idea  of  a  direct 
connection  between  the  tAvo  conditions. 
Four  cases  in  which  thyroid  treatment 
was  resorted  to  to  overcome  dwarfing  in 
children,  in  which  normal  height  was 
reached.  J.  J.  Schmidt  (Therap.  Woch., 
Nov.  15,  '96). 

In  nine  cases,  including  four  idiots, 
large  doses  of  sheep's  thyroid  (half  a 
lobe  every  day  or  every  second  day) 
given.  The  way  most  of  them  gained  in 
height  was  most  remarkable.  In  one  the 
gain  amounted  to  2  Vs  inches  in  five 
months.  Eoullenger  (Pediatrics,  Mar.  15, 
'97). 

Case  of  cretinism  in  which  patient  was 
30  years  of  age,  and  resembled  a  child  of 
7  or  8  years  as  to  height.    Under  thyroid 
extract  improvement  was  marked,  in  2  V: 
years    the    increase    in    height    being    7 
centimetres.      W.    Sinkler    (Phila.    Med. 
Jour.,  May  7,  '98). 
Cretinism. — Clinical  and  experimen- 
tal evidence  have  demonstrated  that  ah- 
sence  or  impotence  of  the  th^Toid  gland, 
as  a  result  of  insuffieient  development, 
removal,  or  neoplastic  overgrowth,  leads 
to  a  general  condition   at  least  closely 


allied  to  that  witnessed  in  cretinism, 
while  symptoms  of  myxoedema  are  pre- 
eminent in  the  majority  of  cases.  That 
much  was  expected  from  thyroid  as  a 
remedial  agent  need  hardly  be  empha- 
sized. 

It  may  be  said  that  the  hopes  enter- 
tained have  been  fully  realized.  The 
mental  condition  is  greatly  improved 
and  the  stunted  growth  is  counteracted. 
As  the  patient  approaches  the  height 
normal  to  his  age  the  growth  continues 
at  the  normal  ratio.  The  myxoedema- 
tous  symptoms  are  rapidly  removed,  the 
abnormal  appearance  being  thus  in  great 
part  corrected.  If  begun  early  in  the 
disease  and  continued  systematically,  the  , 
treatment  seems  capable  of  finally  re- 
storing the  patient  to  a  comparatively 
normal  condition. 

In  a  recent  paper  Osier  was  able  to 
collect  sixty  cases  of  sporadic  cretinism 
which  had  been  observed  in  America, 
demonstrating  that  the  disease  is  not 
limited  to  European  countries,  as  thought 
by  many. 

Case  of  cretinism  in  which  mental  as 
well  as  physical  condition  improved. 
Immediately  upon  the  exhibition  of  the 
remedy  and  at  the  close  of  the  first  week 
a  decided  decrease  in  weight  was  ob- 
served. At  the  end  of  the  first  two 
months  he  had  lost  twenty-two  pounds 
and  gained  over  an  inch  in  height.  Gen- 
eral condition,  physical  as  well  as  mental, 
has  considerably  improved.  H.  H.  Vinke 
(Med.  News,  Mar.  21,  '96). 

Cretin  child  under  treatment  by  thy- 
roid about  two  years  in  an  intermittent 
and  rather  unsatisfactory  manner,  af- 
forded clear  proof  of  the  value  and 
potency  of  the  treatment.  Every  time 
it  was  begun  the  child  underwent  a  rapid 
and  striking  improvement;  every  time 
the  treatment  was  neglected  the  child 
relapsed  into  its  former  cretinoid  appear- 
ance, although  it  never  became  so  bad 
as  it  was  at  first.  Finlayson  (Glasgow 
Med.  Jour.,  May,  '96). 


ANIMAL  EXTRACTS.     THYROID.     CRETINISM. 


365 


Table  of  Published  Cases  of  Cretinism  Treated  by  Thyroid  Administration. 

Found  in  Literature  up  to  May  1, 1896,  by  Fieflerick  Peterson  and  Pearce 
Bailey  (Pediatrics,  May  1,  '96). 


Author 

and 

Reference. 

Symptoms. 

2      H 

D      Ed 

Character 

OF 

Treatment. 

Results. 

Robin. 

Lyon  Med., 

1892,  Ixx,  p. 

405. 

F. 

7  yrs. 

Con- 
genital. 

Characteristic. 
Unable  to 
walk  or  talk. 

Not 
stated. 

Extract  fol- 
lowed by 
implantation. 

Complete  change  in  ap- 
pearance.   Walks. 

Carinicliael. 

Lancet.  1893, 

i,  p.  580. 

F. 

8K  yrs. 

Con- 
genital 

(?). 

Characteristic 

appearance. 

Intelligence 

limited. 

Unable  to  walk 

or  talk. 

9  mos. 

Hyp.  inject,  of 

extract  and 

feeding  of  raw 

gland. 

Skin  became  normal. 
Learned  to  walk  and 
run.  Intelligence  im- 
proved. 

Evans. 
Br.  Med.  Jour., 
1893,  i,  p.  767. 

M. 

8  yrs. 

Not 
stated. 

Not  stated. 

6  weeks. 

One  lobe  of 

sheep's 

thyroid  twice 

a  week. 

No  improvement. 

Hellier. 

Lancet.  1893, 

ii,  p.  1117. 

F. 

2^3  yi's. 

1-2  yrs. 

Characteristic 

appearance. 

Unable  to  walk 

or  talk.  Idiotic. 

i]4  mos. 

Extract. 

CEdematous  symptoms 
gone.  More  intelli- 
gent. Cannot  walk 
or  talk. 

lAinn. 

Br.  Med.  Jour., 

1893,  p.  1273. 

F. 

26  yrs. 

Not 
stated. 

Idiotic. 

No 

other  details. 

Not 
stated. 

Not  stated. 

Became  relatively  in- 
telligent and  men- 
struation was  re- 
sumed. 

Ord. 

Lancet.  1893, 

ii,  p.  1113. 

F. 

6%  yrs. 

Con- 
genital 

Characteristic 

appearance. 

Could  not  walk 

or  talk. 

8  mos. 

Had  been 

grafted 

previously  with 

temporary 

benefit.    Raw 

gland  and 

extract. 

Great  improvement. 
Learned  to  walk  in 
three  months.  Can 
talk. 

Ibid. 

M. 

3  yrs. 

Con- 
genital 

Could  not  talk. 

Always 

dwarfed  and 

bow-legged. 

Skin  dry. 

8  mos. 

Raw  gland, 
dried  gland, 
and  extract. 

Marked.  Learned  to 
talk.  Growing  rap- 
idly. 

Ibid. 

M. 

9inos. 

Not 
stated. 

Typical. 

Improved  rapidly,  but 
died  of  intercurrent 
diphtheria. 

Ibid. 

M. 

9Myrs. 

In 

infancy. 

Characteristic 

physically, 

but  intelligent. 

Height,  34  in. 

Could  walk. 

8  mos. 

Compressed 
extract. 

Grew  1)4  inches  in  four 
months.  Improve- 
ment in  other  respects 
not  so  marked. 

0 

F. 

26  yrs. 

In 
infancy. 

Characteristic. 

Tabloids. 

Injprovement. 

Br  Med.  Jour., 
1893.  p.  1273. 

Height,  40J^  in. 

Patterson. 

Lancet.  1893, 

ii,  p.  11 16. 

M. 

19  mos. 

12  mos. 
(V). 

Char.acteristic. 

8  mos. 

Extract. 

CEdematous  symptoms 
gone.  Can  stand. 
Learning  to  talk.  Has 
sixteen  teeth. 

Veinieliren. 

Dent.  med. 

Wodi..  1893, 

ji.  2.58. 

F. 

29  yrs. 

24  yrs. 

Characteristic. 

3  weeks. 

Thyroidin. 

Marked  improvement. 

Wood 

F. 

lyr. 
11  mos. 

1  mo. 

Had  been 

grafted. 

Raw  gland. 

One  month's  feeding 
without  benefit. 

Anst.  Med.Jr., 
1893,  p.  166. 

366 


ANIMAL  EXTRACTS.    THYROID.    CRETINISM. 


Table  of  Published  Cases  of  Cretinism  Treated  by  Thyroid  Administration. 
{ Continued. ) 


Author 

and 

Reference. 


Character 

of 
Treatment. 


Rehn. 

Ver.  der  XII 

Cong.,  1893, 

p.  224. 

Ibid. 


Anson. 

Lancet,  1S94, 

i,  p.  1063. 


Bramwell. 

Br.  Med.  Jour., 

1894,  i,  p.  6. 


Coniby. 
Med.  Enfant., 
1894,  i,  p.  578. 


Crary. 

Am.  Journal 

Meel.  Sciences, 

1894,  p.  529. 


Garrod, 
Br.  Med.  Jour., 
1894,  ii,  p.  1112. 

Lendou. 

Aust.  M.  Gaz. 

1894,  p.  154. 


Korthrup. 

N.  Y.  Medical 

Jour.,  1894, 

60,  p.  505. 


Osier. 

N.  Y.  Medical 

Jour.,  1894, 

60,  p.  505. 


Railton. 
Br.  Med.  Jour. 
1894,  i,  p.  1180. 


m  yrs. 


6%  yrs. 


16}^  yrs. 


5  yrs. 


12  yrs. 


3  yrs. 


Con- 
genital. 


Characteristic. 


Characteristic. 


Cliaracteristic 

appearance. 

Could 

walk  clumsily. 

Mental 
process  slow. 

Typical. 

Idiotic.  Height, 

29M  in- 


Characteristic 

appearance. 

Cainiot  walli  or 

talk. 


Dwarfed,  lor- 
dosis, impaired 
intelligence. 

Characteristic. 


Heiglit,  32  in. 

Weight,  25  lbs. 

Loss  of 

sphincteric 

control. 

Height.  3  ft., 

3%  in.    Growth 

in  six  years 

only  2^  in. 


Characteristic. 


Characteristic. 

Could  not 
walk  or  talk. 


Characteristic. 

Idiotic. 
Height,  33  in. 


2}^  mos. 


Raw  gland 

and  glycerin 

extract. 


Raw  gland. 


Hypodermic 
injections 
of  extract. 


9  mos. 

Not  stated. 

80  days. 

Extract. 

Not 
stated. 

Not  stated. 

Treatment  not 

systematically 

carried  out. 

11  mos. 

Raw  gland 
and  tahlo.ds. 

Marked  improvement. 


Marked  improvement. 


CEdematous  symptoms 
gone.  Intelligence 
improved.  Grew  4  in. 
(For  three  years  pre- 
viously lia'd  grown 
only  2  inches.) 

(Edematous  symptoms 
disappeared.  More 
intelligent.  Grew  6^ 
inches. 


Great  improvement 
mentally  and  physic- 
ally. 


Improveme  n  t  —  then 
fever,  bronchitis,  and 
death. 


Grew  4%  inches. 


Much  improved. 


Results  not  marked. 


CEdematous  symptoms 
all  disappeared. 
Walks  and  talks. 
Grew  4  inches. 

No  material  gain. 


CEdematous  symptoms 
d.sappeared.  Cannot 
ta.k  well.  Grew  3 
inches. 


ANIMAL  EXTEACTS.    THYROID.    CEETINISM. 


367 


Table  of  Published  Cases  of  Cretinism  Treated  by  Thyroid  Administration. 

{Concluded.) 


Author 

AND 

Reference. 

a 
to 

Age  at 
Beginning 

OP 

Treatment. 

Symptom.s. 

Character 

OF 

Treatment. 

Results. 

Smith. 
Br.  Med.  Jour., 
1894,  i,  p.  1178. 

M. 

9  yrs. 

7  yrs. 

Not  a  severe 
case. 

9  mos. 

Raw  gland 
and  tabloids. 

Improvement. 

Thomson. 

Edin.  Medical 

Jour.,  1894, 

Feb.,  p.  720. 

M. 

18  yrs. 

16  yrs. 

Characteristic. 

Mind  that  of 

a  child  of  3 

years.    Height, 

331^  in. 
Waddling  gait. 

12  mos. 

Raw  gland. 

Some  toxic  symptoms. 
Skin  grew  softer 
and  mind  became 
brighter.  Grew  4^ 
inches.  Most  im- 
provement at  first. 

Esclierich. 

Wien.  med. 

Woch.,  1895, 

p.  350. 

F. 

6M  y>-s. 

m  yrs. 

Myxoedema- 
tous  symptoms 

not  marked. 

"A  backward 

child." 

6  mos. 

Raw  glaud  of 
calf. 

Grew  13  centimetres. 

Lebreton. 

Gaz.  Med.  de 

Paris,  1895, 

No.  1,  p.  8. 

M. 

13  yrs. 

12  yrs. 

Characteristic. 
Idiotic. 

Not 
stated. 

Raw  gland, 
sligTitly 
browned. 

Dentition  appeared. 
Growth  resumed. 
Nothing  said  of  intel- 
ligence. 

Lebreton. 

Gaz.  Med.  de 

Paris,  1895. 

No.  3,  p.  31. 

M. 

3  yrs. 

lyr. 

Cliaracteristic. 

1  yr. 

Dried  gland. 

Improved. 

Sinkler. 

Int.  Medical 

Mag.,  1894-'95, 

iii,  p.  785. 

F. 

4  yrs. 

S]4  yrs. 

Characteristic. 

Unable  to 
walk,  talk,  or 
understand. 
Height, 

301^  in. 

3  mos. 

Extract. 

OEdematous  symptoms 
mostly  disappeared. 
Became  more  intel- 
ligent and  began  to 
talk.  Grew  214  inches. 

West. 

Arch,  of  Ped., 

1895,  p.  348. 

F. 

17  mos. 

Con- 
genital. 

Stupid. 

Height,  2314  in. 

Weight,  14J^ 

lbs. 

No  teeth. 

6  mos. 

Desiccated 
extract. 
Glycerin 
extract. 

CEdematous  symptoms 
disappeared.  Eight 
teeth.  Grew 4 inches. 
Intelligent. 

Fruitnight. 

Arch,  of  Ped., 

1896,  p.  143. 

M. 

4  yrs. 

3  yrs. 

Cannot  walk  or 

talk.    Height, 

25  in. 

Weight,  16K 

lbs. 

Imo. 

Dried  gland. 

Grew  thinner  and  more 
intelligent. 

Noyes. 

N.  Y.  Medical 

Jour.,  1896, 

68,  p.  334. 

F. 

2  yrs. 

1  yr., 
10  inos. 

Characteristic. 
Height,  24  in. 

4K  mos. 

Tablets. 

CEdematous  symptoms 
gone.  Intelligence 
improves.  Begun  to 
creep.  Grew  8  inches. 

Parker. 
Br.  Med.  Jour., 
1896,  i,  p.  333. 

F. 

6J^  yrs. 

Con- 
genital 

Typical. 

12  mos. 

Tabloids. 

CEdematous  symptoms 
disappeared.  Learned 
to  walk.  Did  not 
learn  to  talk. 

F  Peterson 

M. 

18  mos. 

(?) 

10  mos. 

One  grain 
extract  daily. 

Probably  cured. 

and  P.  Baile.v, 
Ped.,Mayl,'96. 

Jbid. 

F. 

15  yrs. 

(?) 

3  mos. 

One  giain 
extract  daily. 

Great  improvement. 

Vinke. 

Med.  News, 

1896, 

68,  p.  309. 

M. 

6  yrs. 

Con- 
genital. 

Characteristic 
appearance. 

Can  walk  and 
talk  a  little. 

5  mos. 

Tablets. 

Marked  improvement 
in  all  symptoms. 

368 


ANIMAL  EXTRACTS.    THYROID.    CRETINISM. 


Case  of  a  cretiiij  nearly  18  years  old, 
so  stunted  as  to  be  easily  mistaken  for 
a  child  aged  2  or  3  years;  she  could  not 
stand  or  walk  or  speak.  On  October 
15th  she  began  taking  half  of  a  5-grain 
thyroid  tabloid  daily,  and  within  the 
first  week  she  became  much  brighter  and 
quicker  in  noticing  things;  she  also  lost 
one  and  three-fourths  pounds.  During 
the  second  week  she  lost  two  pounds 
more;    made  very  ill,  hot,  feverish,  rest- 


and  three-fourths  inches  in  the  first  year 
of  treatment^  four  and  one-fourth  inches 
in  the  second  year,  and  two  and  one-half 
inches  in  the  third  year.  In  two  adult 
cretins,  36  and  39  years  of  age,  the 
growth  in  one  was  three-fourths  of  an 
inch  and  five-eighths  of  an  inch  in  the 
first  and  second  years,  and  none  in  the 
third.  J.  Thomson  (Brit.  Med.  Jour.,  vol. 
ii,  p.  618,  '96). 

Cretins    whose    bones    show    signs    of 


Case  of  typical  sporadic  cretinism.  Appearance  Avheu  treatment  was  begun.  After 
eighteen  months'  treatment  he  had  grown  nine  inches  and  the  mental  condition 
had  improved  correspondingly.     (  Vinke. ) 


less,  parched,  and  thirsty.  During  the 
third  week  she  lost  one  and  one-half 
pounds  more,  and  became  still  brighter 
and  quicker.  Both  physical  and  mental 
improvement  during  the  first  six  months. 
W.  Rushton  Parker  (Brit.  Med.  Jour., 
June  27,  '96). 

Case  of  a  child,  5  years  of  age,  seven 
inches  below  the  normal  height  at  the 
beginning  of   treatment,   who  grew   five 


softening  should  be  kept  lying  down  as 
they  would  be  in  ordinary  rickets.  Victor 
Horsley  (Brit.  Med.  Jour.,  Sept.  25,  '96). 
During  thyroid  treatment  the  rapid 
growth  of  the  skeleton  leads  to  a  soft- 
ened condition  of  the  bones,  which  re- 
sults in  a  yielding  and  bending  of  those 
which  have  to  bear  weight;  as  cretins 
under  treatment  become  more  active  and 
inclined  to  run  about,  this  tendency  to 


ANIMAL  EXTRACTS.    THYROID.    CRETINISM. 


369 


bending  has  to  be  guarded  against.  If 
any  bending  of  the  bones  of  the  legs 
appears,  the  child  should  not  be  allowed 
to  walk  for  a  time,  or  the  legs  should 
be  supported  by  light  splints.  The  diet 
should  be  generous,  and  the  child  should 
get  plenty  of  sunlight  and  open  air.  The 
administration  of  codliver-oil  and  Par- 
rish's  food  would  probably  prove  bene- 
ficial at  the  same  time.  T.  Telford- 
Smith  (Lancet,  Oct.  2,  '97). 

Case  in  which  all  the  symptoms  of  in- 
fantile myxoedema  were  present:    idiocy, 


tins.      M.    H.    Fussell    (Med.    and   Surg. 
Reporter,  Feb.  20,  '97). 

Three  cases  in  two  brothers  and  sis- 
ter. The  two  older  marked  cretins,  tlie 
younger  being  quite  a  typical  case, 
■while  the  baby  has  the  cretinoid  tend- 
ency well  marked.  Thyroid  treatment 
instituted.  The  baby's  present  condition 
is  quite  that  of  a  normal  child.  The 
cases  of  the  two  older  are  less  promising 
as  to  final  results,  although  they  have 
shown  improvement  in  many  ways.  C. 
S.  Caverly  (Med.  Record,  Apr.  10,  '97). 


I 

^£       ^C'  - 

1 

Li 

1 

Fig.  1  Fis.  2. 

Cretin  nearly   18  years  of  age.     Fig.  1.  Before  treatment.     Fig.  2.  Sis  months  after 

treatment  by  thyroid  extract.     {Ruslitnn  Parker.) 


dwarfism,  absence  of  the  thyroid  gland, 
retarded  dentition,  pachydermic  denti- 
tion, etc.  Effects  of  thyroid  treatment 
remarkable.  Suspension  of  treatment: 
reappearance  of  almost  all  symptoms. 
Treatment  was  resumed  and  child  trans- 
formed physically  and  intellectually. 
Rourneville  (Le  Prog.  Med.,  Mar.  6,  '97). 
Three  cases  improved  markedly  after 
taking  thyroid  three  times  a  day  in 
1-graJn  doses;  they  could  be  classed  with 
those  mentioned  by  Horsley  as  being 
■bom  with  but  few,  if  any,  signs  of  the 
■disease,  and  who  gradually  become  cre- 

1—24 


Four  cases  of  cretinoid  myxcedema  in 
which  thyroid  extract  in  small  doses 
(2  V::  grains  twice  a  week)  was  used 
with  success.  It  is  a  great  deal  better 
to  begin  with  small  doses  two  or  three 
times  a  week,  even  if  the  desired  results 
are  obtained  more  slowly,  than  to  deluge 
the  patient  with  it.  J.  C.  Shaw  (Brook- 
lyn Med.  Jour.,  -Jan..  '97). 

Case  of  a  child,  nearly  8  years  old, 
typical  of  cretinism,  put  under  desic- 
cated thyroid  1  'A  grains  t.  i.  d.,  but, 
the  remedy  being  administered  irregu- 
larly, the  patient  was  taken  into  a  hos- 


370 


ANIMAL  EXTRACTS.    THYROID.    CRETINISM. 


pital.  It  was  then  found  that  6  grains 
daily  was  her  maximum  dose,  and  on 
this  amount  she  very  rapidly  improved. 
At  the  end  of  four  months  (seven  from 
the  beginning  of  treatment)  she  had 
gained  four  inches  in  height,  four  pounds 
in  weight,  and  had  begun  to  act  like  a 
normal  child.  Dickson  L.  Moore  (Colum- 
bus Med.  Jour.,  Apr.  13,  '97). 

Case  of  advanced  cretinism  in  Hindoo 
boy  treated  by  thyroid  extract.  Thyroid 
treatment  was  begun  by  administration 


as  the  thyroid  extract.  After  a  fort- 
night signs  of  the  reflex  returned;  pa- 
tient became  much  stronger  on  his  legs. 
H.  E.  Drake-Brockman  (Lancet,  Oct.  2, 
'97). 

Case  of  a  child  who  presented  a  typ- 
ically cretinoid  appearance  when  first 
seen  in  February,  1896,  then  5  years  old. 
Mentally  deficient.  Given  one  5-graiD 
tabloid  of  thyroid  extract  (Burroughs, 
Wellcome  &  Co.)  daily,  which  raised  the 
temperature  to  102°  F. ;    dose  reduced  to 


Case  of  cretinism.     Result  of  four  months'  treatment.     Growth,  4  inches, 
approaching  normal.     (Moore.) 


of  3  grains  of  the  dry  extract  by  the 
mouth  daily.  Thyroid  enlargement  di- 
minished fully  two  inches  in  the  space 
of  one  month;  the  lad,  both  physically 
and  mentally,  had  shown  marked  im- 
provement. Dose  increased  to  5  grains 
daily.  Marked  and  steady  improvement 
continued,  but  marked  absence  of  patel- 
lar reflex:  a  prominent  symptom  in 
tabes  dorsalis,  in  which  Brown-Sfiquard 
has  used  orchitie  fluid.  Administered  to 
patient  5  grains  of  didymin  daily,  as  well 


one-half.  Gradual  improvement.  Weight 
fell  at  first  to  twenty  pounds,  and  then 
slowly  increased,  the  cretinoid  aspect  dis- 
appeared, and  the  intelligence  steadily 
improved.  Continued  to  take  smaller 
quantities  of  the  extract,  and  has  de- 
veloped into  a  healthy  child,  weighing 
thirty-seven  pounds,  and  measuring 
thirty-seven  and  one-half  inches  in 
height.  No  thyroid  gland  could  be  de- 
tected on  palpation.  W.  Carr  (Brit.  Med. 
Jour.,  Nov.  13,  '97). 


ANIMAL  EXTRACTS.     THYROID.     CRETINISM. 


371 


Case  of  a  girl,  aged  10  years,  who  first 
came  under  observation  in  June,  1897, 
and  had  not  previously  been  ti'eated  with 
thyroid  gland.  She  was  then  9  Va  years 
old,  weighed  thirty  pounds,  and  was  two 
feet  and  ten  inches  in  height;  legs  short, 
with  lordosis  and  prominence  of  the  ab- 
domen. She  was  in  the  second  standard 
at  school.  During  four  months  of  thy- 
roid treatment  grew  two  and  one-half 
inches,  fatty  masses  disappearing  from 
her  neck.  Expression  lively  and  intelli- 
gent. W.  S.  Coleman  (Brit.  Med.  .Jour., 
Nov.  13,  '97). 

Case  with  numerous  abscesses  which 
healed  as  soon  as  the  child  was  put  under 
the  thj'roid  treatment.  Hgemoglobin  in- 
creased from  25  to  75  per  cent.,  child  not 
haying  done  well  on  the  daily  doses  of 
from  V4  to  V2  grain  of  the  thyroid  ex- 
tract, this  attributable  not  only  to  the 
small  doses  of  the  thyroid,  but  to  the 
use  of  a  bad  preparation. 

Case,  in  which  cold  hands  showed 
weak  circulation,  greatly  improved  when 
the  preparation  was  changed.  It  seemed 
that  the  dose  must  be  increased  as  the 
child  grew  older.  These  children  should 
be  kept  upon  the  largest  doses  of  thy- 
roid they  will  stand  without  having  an 
elevation  of  temperature.  H.  Koplik 
(Pediatrics,  Nov.  15,  '97). 

Case  of  cretinism,  after  two  years  of 
treatment,  very  remarkably  improved. 
During  the  first  year  of  treatment  an 
attempt  was  made  to  keep  the  child  on 
as  large  a  dose  of  the  thyroid  extract 
as  possible.  It  was  found  after  trial  that 
the  child  did  best  on  1  grain  a  day. 
After  nine  months  1  ^U  grains  (Parke, 
Davis  &  Co.),  twice  a  day.  During  the 
first  year  of  treatment  she  grew  eight 
and  one-fourth  inches  and  gained  four- 
teen pounds:  i.e.,  nearly  doubled  her 
weight.  After  she  had  been  under  treat- 
ment a  year  the  thyroid  was  stopped, 
and  during  that  time  the  peculiar  ap- 
pearance of  the  cretin  returned  and  she 
became  much  more  stupid.  She  was  then 
put  back  on  1  V,  grains  a  day,  and  this 
was  kept  up  until  the  first  of  this  year. 
Since  then  she  has  had  1  'A  grains  twice 
a  week,  on  alternate  weeks.  J.  P.  West 
(Pediatrics,  Nov.  15,  '97). 

In  sporadic  cretinism  the  fresh  thyroid 


gland,  the  desiccated  gland,  and  even  the 
colloid  substances  have  been  found  al- 
most equally  efficacious.  The  preparation 
used  should  be  free  from  decomposition- 
products.  Half  a  grain  of  the  desiccated 
gland  may  be  at  first  given  two  or  three 
times  a  day,  the  dose  increased  in  a  week 
or  two  to  1  grain,  and  later  this  may 
be  increased  if  improvement  is  not  satis- 
factory. If  unpleasant  effects  result,  the 
dose  should  be  lessened  or  a  fresh  prepa- 
ration tried.  A.  McPhedran  (Canadian 
Jour,  of  Med.  and  Surg.,  vol.  iv,  p.  275, 
'98). 

Mental  Development  Following  Treat- 
ment with  Thyroid.  —  The  alteration  in 
the  mental  condition  is  noticed  within 
a  couple  of  months.  The  patients  look 
much  brighter  and  the  face  is  not  ab- 
solutely expressionless.  As  a  rule,  ihe 
younger  the  case,  the  more  marked  is 
the  mental  change.  Young  cretins  who 
have  not  learned  to  speak  a  word  soon 
begin  to  talk  in  their  play.  In  children 
between  six  and  ten  the  effects  are  even 
more  remarkable,  and  with  the  loss  of 
the  myxoedematous  condition  there  is  a 
corresponding  awakening  of  the  mental 
faculties.  In  older  patients  the  treat- 
ment is  not  so  etficacious.     (Osier.) 

A  grain  of  the  desiccated  gland  three 
times  a  day  in  young  cretins  is  the  dose 
preferred  by  Osier,  but,  as  already  stated, 
its  effects  should  be  carefully  watched 
and  the  amoxmt  reduced  if  the  pulse 
becomes  more  rapid  or  if  there  is  fever. 
Older  patients  may  take  as  much  as  5 
grains  in  the  day,  and  the  amount  may 
be  diminished  as  the  symptoms  indicate. 
Young  patients  bear  the  remedy  very 
well,  and  in  a  few  months,  if  no  im- 
provement is  noted,  larger  doses  must 
be  tried,  without,  however,  relinquishing 
watchful  care. 

Case  of  cretinism  in  a  girl,  14  years  of 
age,  in  which  the  thyroid-gland  treat- 
ment was  instituted  and  followed  by 
a  very  slow  improvement  mentally  and 
a    much    more   marked    one    physically. 


372 


ANIMAL  EXTRACTS.    THYROID.     CUTANEOUS  DISEASES. 


After  undergoing  the  treatment  at  ir- 
regular periods  during  about  nineteen 
montlis,  her  temperature  suddenly  rose 
to  104°  ¥.,  her  pulse  to  160,  and  respira- 
tion became  so  short  and  thick  that  it 
was  only  with  difficulty  they  could  be 
counted.  At  this  time  she  was  taking 
6  grains  of  thyroid  extract  daily.  Medi- 
cation was  immediately  stopped,  but  her 
condition  remained  the  same,  with  one 
remission  of  temperature  and  pulse-rate, 
during  two  days,  when,  on  January  22d, 
at  one  o'clock  in  the  afternoon,  she  died. 
S.  H.  Friend  (Med.  News,  Dec.  4,  '97). 

Case  of  cretinism;  after  the  age  of  30 
years  the  patient's  height  increased 
nearly  three  inches  through  the  adminis- 
tration of  thyroid  (3  grains  three  times 
a  day)  only;  menstruation,  which  had 
not  appeared  until  the  age  of  26,  then 
occurred  scantily  at  intervals  of  three  or 
four  months,  became  regular  and  normal; 
four  additional  teeth  were  cut,  and  her 
intelligence  was  much  improved.  Whar- 
ton Sinkler  (Phila.  Med.  Jour.;  Alienist 
and  Neurol.,  Oct.,  '99). 

Unpleasant  effects  are  less  commonly 
seen  than  in  the  myxcBdema  of  adults. 
After  the  disappearance  of  the  myxce- 
dema  and  the  establishment  of  the  proc- 
esses of  growth  and  development,  a  very 
moderate  dose  seems  sufficient:  1  or  2 
5-gTain  tablets  a  week.  Osier  has  noticed 
that  an  intermission  for  a  month  or  six 
weeks  does  not  seem  to  be  followed  by 
any  striking  change,  but  an  intermission 
for  a  longer  period  is  followed  by  symp- 
toms indicating  a  relapse.  This  is  clearly 
shown  in  the  eases  quoted  above. 

Thyroidin  has  proven  of  value  and 
might  be  used  instead  if,  for  any  reason, 
the  more  reliable  preparations  cannot  be 
employed. 

Case  of  cretinism  successfully  treated 
with  thyroidin,  in  a  girl  of  11  years,  who 
first  manifested  symptoms  of  her  condi- 
tion at  the  age  of  three  years.  Her  men- 
tal condition  was  of  a  very  low  type. 
Two  and  one-half  grains  of  thyroidin 
were  given  every  other  day,  increased  to 
5,  and  still  later  to  7  'A  grains  every  day. 


The  improvement  was  rapid  from  the  be- 
ginning  of   the   treatment,   growth    and 
mental  development  keeping  up  with  the 
general  progress.     C.  M.  Anderson  (Lan- 
cet,  Oct.  2,  '97). 
Prevention  of  Cretinism.  ■ —  The  cases 
observed  by  Gordon  Paterson  would  tend 
to  demonstrate  that  the  administration 
of  thyroid  extract  during  pregnancy  to  a 
woman  who  had  previously  given  birth 
to  cretins  would  so  modify  her  phj'sio- 
logical  functions  as  to  render  her  capable 
of  bringing  forth  normal  children. 

Treatment  of  a  mother  in  her  third 
pregnancy,  from  the  beginning  of  the 
third  month,  who  had  given  birth  to  two 
cretins  in  successive  pregnancies.  One 
tabloid  taken  every  day  during  the  re- 
maining seven  months  of  the  pregnancy. 
At  no  time  did  she  suffer  from  any  dis- 
comfort; on  the  contrary,  was  much 
better  throughout  than  she  had  been  in 
the  previous  pregnancies.  The  child  was 
a  fine,  healthy  female,  indistinguishable 
from  any  other  infant  in  appearance.  At 
the  age  of  5  months,  the  infant  is  re- 
markably fine  and  intelligent  and  can 
sit  up  finely.  She  is  now  able  to  stand 
and  to  say  several  words  and  is  11 
months  old.  A.  Gordon  Paterson  (Lan- 
cet, Oct.  2,  '97). 

Cutaneous  Diseases. — The  hopes  at 
first  entertained  have  been,  to  a  great 
degree,  dispelled  by  the  results  obtained. 
In  psoriasis  thyroid  extract  has  not  shown 
itself  as  effective  as  other  forms  of  treat- 
ment. In  lupus  and  leprosy  indications 
would  seem  to  warrant  further  trial.  The 
same  might  be  said  of  keloid. 

According  to  Don,  who  used  thyroid 
gland  with  advantage  in  cases  of  ichthy- 
osis, there  is  no  doubt  that  it  is  strongly 
stimulating  by  directly  increasing  the 
cutaneous  circulation,  as  evidenced  in 
sensations  of  flushing,  hot  tingling,  and 
congestive  irritation,  frequently  felt  as  a 
precursor  to  ordinary  perspiration.  The 
increased  cutaneous  vascular  supply  ap- 
parently results  in:    1.  Increased  nutri- 


AXIMAL  EXTRACTS.     THYROID.     PSORIASIS. 


373 


tion  of  the  skin;  hence  its  probable  re- 
medial action  in  ichthj'otic  conditions: 
an  effect  produced  without  any  necessary 
abnormal  perspiration.  2.  Increased  ac- 
tion of  the  cutaneous  glands,  accelerating 
excretion  of  waste-products,  thus  keep- 
ing the  surface  in  a  supple  condition.  3. 
Eegrowth  of  hair,  as  shown  in  myxoe- 
dema  and  some  cases  of  general  alopecia. 
4.  Increased  activity  of  the  epidermal 
layers,  cavising  desquamation  of  un- 
healthy epidermis  and  reproduction  of  a 
new  covering,  as  observed  in  ichthyosis, 
psoriasis,  dry  chronic  eczema,  and  also  in 
some  cases  of  myxoedema  and  cretinism. 
In  other  diseases,  however,  in  which 
the  remedy  was  employed  the  results 
have  been  such  as  not  to  warrant  fur- 
ther trial.  Indeed,  the  untoward  effects 
sometimes  attending  its  administration 
and  the  imcertainty  of  the  results  have 
caused  many  dermatologists  to  abandon 
its  use  altogether. 

The  use  of  thyroid  extract  is  only  per- 
missible when  the  patient  can  be  kept 
constantly  under  observation,  because  of 
the  severe  and  sometimes  dangerous 
symptoms  which  it  produces.  Zarubin 
(Arehiv  f.  Dermat.  u.  Syph.,  B.  37,  H.  3, 
"96). 

The  thyroid  extract  has  certain!}'  no 
specific  action  in  scleroderma,  as  it  has 
in  myxcedema.  In  no  case  did  the  skin 
of  the  affected  regions  become  softer  or 
regain  its  natural  appearance.  In  two 
cases  the  disease  did  not  progress  under 
its  use.  Two  of  the  cases — one  with 
tacliycardia — took  it  for  eighteen  months, 
and  another  for  nineteen  months,  with- 
out any  ill  effects;  the  latter  case  gained 
weight.  AV.  Osier  (Jour,  of  Gut.  and 
Genito-Urin.  Dis.,  Mar.,  '98). 

Curative  effects  observed  in  urticaria. 
The  extract  was  being  used  for  obesity 
with  chronic  and  persistent  constipa- 
tion. The  patient  for  several  years  had 
been  a  victim  of  urticaria.  She  had 
been  treated  at  various  times  with  no 
results.  Two  hundred  5-grain  tablets  of 
the  extract  were  taken  at  the  rate  of 


three  per  day.  From  the  third  day 
(eight  months  ago)  she  has  not  been 
troubled  either  with  the  constipation 
or  the  urticaria,  though  the  obesity  was 
not  influenced.  J.  N.  Roussel  (New 
Orleans  Med.  and  Surg.  Jour.,  April, 
1902). 

Psoriasis. — Of  all  the  skin  afEections 
psoriasis  is  the  only  one  in  which  thy- 
roid extract  seems  to  have  proved  bene- 
ticial  in  a  reasonable  proportion  of  the 
cases  in  which  it  was  used.  But  at  best 
its  effects  are  not  to  be  relied  upon,  and 
it  should  only  be  tried  after  arsenic  and 
other  standard  measures  have  been  fully 
tried. 

Four  cases  of  psoriasis  treated  by  thy- 
roid extract,  in  the  form  of  pastilles. 
Two  daily,  equivalent  to  one  thyroid 
gland,  were  given.  One  of  the  patients 
took  thyroid  gland  daily.  In  none  of  the 
ca.ses  did  any  improvement  result  from 
the  use  of  the  medicament.  The  inges- 
tion of  a  thyroid  gland  in  one  case  pro- 
duced a  febrile  condition,  nausea,  and 
diarrhoea,  without  any  manifestations  of 
acute  dermatitis.  Menau  (I'Encephale, 
June  10,  '94). 

Results  in  twenty  cases  of  psoriasis: 
In  a  very  considerable  proportion  of  cases 
the  thyroid  treatment  produces  a  tempo- 
rary cure,  the  eruption  entirely  disap- 
pearing and  the  skin  being  left  in  an 
absolutely  healthy  condition.  In  excep- 
tional cases  small  doses  produce  a  rapid 
improvement,  while  in  others  improve- 
ment is  only  produced  after  distinct 
symptoms  of  thyroidism.  Some  obstinate 
eases  ultimately  yield  to  very  large  doses, 
continued  for  a  long  time. 

Xo  case  should  be  regarded  as  hopeless 
unless  thyroidism  has  been  produced,  the 
largest  dose  which  the  patient  can  take 
having  been  continiied  for  at  least  two 
months.  In  several  cases  the  first  effect 
of  the  remedy  is  to  produce  an  extension 
of  the  eruption,  this  being  most  marked 
in  cases  in  which  the  treatment  is  most 
successful.  In  some  cases  the  treatment 
produces  no  effect.  Relapses  are  not 
prevented.  Long-standing,  chronic  cases 
are  more  readily  cured  than  the  more 
recent  ones.   Treatment  begun  with  small 


374 


ANIMAL  EXTRACTS.    THYROID.     LUPUS. 


doses  and  increased  until  distinct  symp- 
toms of  thyroidism  are  produced.  Byrom 
Bramwell  (Jour,  of  Dermatology,  July, 
'94). 

Disappointed  with  the  effect  of  thy- 
roid in  psoriasis.  Although  some  of  the 
cases  treated  had  been  benefited  in  a 
marked  manner,  the  majority  had  not. 
Even  in  the  cases  that  had  been  improved 
equally  good  results,  with  much  less  dis- 
turbance of  the  patient's  health,  would 
have  been  achieved  by  the  vigorous  use 
of  external  remedies,  such  as  ointments 
and  baths.  P.  S.  Abraham  (Med.  Press 
and  Circular,  Jan.  2,  '95). 

Thyroid  treatment  has  a  limited 
sphere  of  usefulness ;  unsuited  for  elderly 
patients  with  weak  hearts.  Radoliffe- 
Crocker   (Lancet,  June  8,  '95). 

Twenty-four  cases  of  psoriasis,  eleven 
of  which  were  cured  and  seven  were  im- 
proved by  the  treatment.  In  a  few  cases 
even  tolerably  large  doses  seemed  to  have 
hardly  any  effect.  It  does  not  seem  at 
present  possible  to  distinguish  before- 
hand those  cases  of  psoriasis  which  are 
benefited  by  the  treatment  from  those 
which  derive  no  benefit.  Zum  Busch 
(Derm.  Zeit.,  Sept.,  '95). 

Cases  successfully  treated  by  thyroid 
extract.  Wilson  (Brit.  Med.  Jour.,  Feb. 
16,  '95) ;  Preeee  (Brit.  Med.  Jour.,  Mar. 
30,  '95) ;  see  Annual,  '96. 

Thyroid  extract  used  in  psoriasis  in 
six  cases,  in  only  one  of  which  it  was 
successful  in  curing  the  disease.  H.  S. 
Purdon  (Dublin  Jour.  Med.  Sciences, 
Nov.  2,  '96). 

Case  of  psoriasis  with  insanity.  The 
patient  was  depressed,  suspicious,  and 
his  memory  was  impaired.  He  was  put 
to  bed  and  thyroid  tablets,  in  15-grain 
doses  three  times  a  day,  were  admin- 
istered. On  the  third  day  a  marked 
change  in  the  mental  condition  was  ob- 
served. He  woke  up  from  his  confused 
lethargy,  appeared  quite  collected,  read 
a  newspaper,  and  took  an  interest  in 
his  surroundings.  His  improvement  was 
steady.  The  thyroid  was  reduced  to 
5  grains  a  day  on  the  eighth  day,  and 
this  amount  was  given  daily  for  an- 
other week.  The  psoriasis  had  entirely 
disappeared  by  the  end  of  the  fourth 
week,  leaving  very  little  scarring.     He 


had  lost  sixteen  pounds  in  weight  dur- 
ing the  treatment,  but  he  soon  regained 
his  lost  flesh.  He  was  discharged  cured 
two  months  after  admission,  and  eight- 
een months  later  had  had  no  return 
of  the  skin  or  mental  affection.  H.  de 
Maine  Alexander  (Lancet,  Dec.  8,  1900). 

Lupus. — In  lupus  vulgaris  thyroid  has 
not  been  extensively  tried,  but  the  bene- 
fit derived  in  a  number  of  cases,  and  the 
unfavorable  results  attending  other  forms 
of  treatment,  warrant  further  investiga- 
tions.   Large  doses  are  required. 

Two  cases  in  which  thyroid  extract 
was  used :  In  the  first,  a  girl  aged  16  '/- 
years,  whose  disease  had  persisted  for 
nine  years,  covering  the  nose,  left  cheek, 
and  upper  lip,  and  extending  from  each 
corner  of  the  mouth  to  the  chin,  admin- 
istration of  the  extract  was  continued, 
with  a  few  intervals,  during  six  months. 
At  the  latter  date  the  improvement  was 
marked.  In  an  intermission  the  disease 
retrograded,  but  improved  again  on  the 
resumption  of  the  thyroid  treatment. 
After  a  year  the  patient  was  much  im- 
proved, not  cured.  The  second  was  a 
girl,  aged  18  years,  whose  nose,  moutn, 
and  right  eyelid  were  affected.  Notice- 
able improvement  was  made  within  a 
month.  Byrom  Bramwell  (Brit.  Med. 
Jour.,  Apr.  14,  '94). 

Case  of  lupus  vulgaris  treated  with 
thyroid  extract  and  linear  scarification. 
Face  wonderfully  improved.  On  passing 
the  finger  over  the  lupus  it  is  found  to 
be  perfectly  smooth  and  the  ulceration 
apparently  healed.  G.  G.  Stopford  Tay- 
lor (Med.  Press  and  Circular,  Oct.  3, '94). 

Cases  in  which  treatment  by  thyroid 
extract  proved  beneficial,  but  not  cura- 
tive. Abraham  (Brit.  Jour,  of  Derm., 
Aug.,  '94) ;  Lake  (-Jour,  of  Laryn.,  Feb., 
'95). 

Fovu-  eases  where  the  results  had  been 
extremely  good.  P.  S.  Abraham  (Med. 
Press  and  Circular,  Jan.  2,  '95). 

Thyroidin  appears  to  cause  local  re- 
action somewhat  resembling  that  caused 
by  tuberculin.  Zum  Busch  (Derm.  Zeit., 
Sept.,  '95). 

Duration  of  treatment  necessary  to 
insure   permanent   cure,   even   with   full 


ANIMAL  EXTRACTS.    THYROID.    EXOPHTHALMIC  GOITRE. 


375 


doses  given  regularly  and  continuously, 
not  shorter  than  one  year.  The  dose  in 
lupus,  as  in  psoriasis,  requires  to  be 
larger  than  what  is  found  sufficient  for 
myxcedema.  The  older  the  patient,  the 
more  cautious  ought  we  to  be  with  the 
quantity  prescribed.  J.  Barclay  (Brit. 
Med.  Jour.,  Oct.  24, '96). 

Two  cases  of  lupus  in  which  the  re- 
sults were  very  successful.    In  both  cases 
there  was  no  bad  symptom.     The  points 
to   be    noted   are    preliminary    scraping, 
the  gradual   increase   in  the  amount   of 
the  drug,  and  the  large  quantity  taken, 
as  much  as  90  grains  a  day  in  one  case. 
Seen   eight   months   later:     in   one    case 
there  was  a  tiny  focus  in  the  interior  of 
the  nose,  and  in  the  other  there  was  no 
return    whatsoever.      F.     G.    Proudfoot 
(Brit.  Med.  Jour.,  Jan.  2,  '97). 
Leprosy.  —  Closely    associated    with 
lupus  is  leprosy,  in  a  few  eases  of  which 
thyroid  gland  has  been  tried.     The  re- 
sults, though  promising,  do  not  warrant 
even  an  estimate  of  its  value,  and  it  is 
hoped  that  its  merits  will  be  further  in- 
vestigated. 

Tried  tabloids  on  the  Trinidad  Leper 
Asylum  patients.  Results  not  encour- 
aging. The  most  powerful  preparation 
of  the  drug  had  been  pushed  as  far  as 
safety  would  allow  in  leprosy.  Bevan 
Rake  (Med.  Press  and  Circular,  Jan.  2, 
'95). 

Two  cases  of  leprosy  treated  by  thy- 
roid gland;    beneficial  influence  on  both. 
Patients  seen  two  years  later  and  found 
apparently  well  and  able  to  earn  their 
living.     The   disease  had  not   advanced. 
C.  B.  Maitland  (Lancet,  Oct.  31,  '96). 
Keloid.  ■ —  Thyroid  extract  has  caused 
disappearance  of  the  hypertrophic  tis- 
sues in  a  case  reported  by  J.  W.  White. 
Case  following  cut  in  which  absorbent 
ointments,  pressure  by  means  of  plaster, 
and  other  means  of  local  treatment  hav- 
ing been  tried  to  no  purpose,  put  upon 
thyroid   extract,   from   2   to   4   tablets — 
each    tablet   containing   5   grains — being 
given  daily.     All  local  treatment  discon- 
tinued, the  scar  covered  with  a  film  of 
collodion  to  prevent  abrasion   of  irrita- 
tion and  to  keep  up  gentle  pressure.    In 


a  few  weeks  a  perceptible  change  noted; 
in  six  weeks  the  scar  had,  in  almost  its 
entire  extent,  come  down  to  the  level  of 
the  surrounding  skin  and  the  dense  base 
had   disappeared.     J.   W.  White    (Univ. 
Med.  Mag.,  Aug.,  '95). 
Epilepsy. — The  four  cases  given  be- 
low would  tend  to  show  that  thyroid 
gland  is  of  no  value  in  this  disorder. 

Cases  selected  for  trial  those  in  which 
many  congenital  defects  were  noticeable, 
and  in  which  epilepsy  had  been  a  promi- 
nent feature  of  the  patient's  life  since 
early  infancy.  The  administration  of 
thyroid  not  attended  with  very  good  re- 
sults. While  all  seemed  to  be  benefited 
for  the  time  being,  permanent  improve- 
ment doubtful.  Trial  subjects  lost  from 
three  to  ten  pounds  in  weight.  The 
results  would  not  seem  to  justify  its 
continued  use  in  epilepsy,  and  its  further 
administration  was  not  attempted.  L.  P. 
Clark  (Med.  Record,  Oct.  24,  '96). 

Exophthalmic  Goithe. — In  the  treat- 
ment of  this  condition  the  various  prepa- 
rations of  thyroid  have  been  found  more 
harmful  than  beneficial  in  many  cases. 

This  would  seem  to  sustain  the  opin- 
ion expressed  by  M.  Allen  Starr,  that 
if  exophthalmic  goitre  is  due  to  hyper- 
activity of  the  thyroid  gland — a  theory 
first  proposed  in  1886,  and  which  has 
gradually  gained  ground  since  then — 
there  is  every  reason  why  the  thyroid 
treatment  should  be  avoided.  The  few 
cases  of  reported  improvement  from  this 
treatment  would  not,  in  his  opinion,  bear 
critical  investigation. 

It  is  probable,  however,  that  in  certain 
cases  thyroid  gland  may  prove  of  value, 
as  shown  in  some  of  the  instances  re- 
ported below,  and  that  we  are  as  yet  in- 
sufficiently informed  to  determine  just 
where  the  remedy  is  applicable.  It 
should  certainly  not  be  employed  indis- 
criminately, and  judging  from  a  review 
of  recent  reports  as  a  whole  the  condi- 
tion of  the  heart  would  seem  to  infl[uence 
the  action  of  the  remedy. 


376 


ANIMAL  EXTRACTS.    THYROID.    EXOPHTHALMIC  GOITRE. 


Case  bj'  thyroid  extract,  with  improve- 
ment at  first,  followed  later  by  deterio- 
ration. The  thyroid  extract  was  reduced, 
then  stopped,  but  the  patient  died  three 
weeks  later.  There  was  great  prolifera- 
tion of  the  thyroid  epithelium.  H.  Power 
(N.  Y.  Med.  Record,  Aug.  11,  '94). 

Nine  eases,  all  markedly  improved. 
In  the  majority  the  improvement  wag 
slow,  though  steady,  but  in  only  one 
did  the  exophthalmos  disappear.  Bogroff 
(Gaz.  Heb.  de  la  Russie  Merid.,  Jan., 
Feb.,  '95). 

In  Graves's  disease  thyroid  treatment 
contra-indicated.  It  is  possible,  however, 
that  when  the  goitre  seems  to  be  the 
primary  trouble  some  .  benefit  may  be 
derived  from  this  agent.  Senator  and 
Mendel  (Berliner  klin.  Woch.,  Feb.  3, 
'95). 

Thyroid  has  no  favorable  influence, 
and  is,  indeed,  likely  to  increase  the  dis- 
comfort, or,  where  the  sj'mptoms  had 
abated,  to  light  them  up  again.  Stabel 
(Berliner  klin.  Woch.,  Feb.  3,  '95). 

Successful  ease  after  the  use  of  a 
quarter  of  a  lobe  eaten  raw  twice  a  day. 
Fergusson  (Brit.  Med.  Jour.,  Oct.  20,  '95). 

Case  in  which  1 '/~  to  2  drachms  of 
sheep's  thyroid  daily  before  meals,  small 
amounts  of  gland  daily,  then  omitting 
use  for  ten  daj's  every  three  weeks,  caused 
all  symptoms  to  disappear  except  slight 
swelling  and  slight  exophthalmos.  Voisin 
(La  Sem.  MSd.,  Oct.  24,  '95). 

Cases  in  which  the  remedj'  aggravated 
the  active  symptoms.  Dreyfus-Brisac 
and  Beclere  (La  Sem.  Med.,  Oct.  24,  '95). 

Three  cases  in  which  good  results  were 
obtained.  Voisin  (Revue  de  Thfirap.,  p. 
728,  '95). 

Patients  who  have  been  treated  with 
thyroid  extract  prior  to  operation  seem 
to  be  more  liable  to  heart-failure  both 
during  and  after  this  proceeding,  and 
one  or  two  deaths  have  been  attributed 
to  this  cause.  Angerer  (Miinchener  med. 
Woch.,  21,  '96). 

Case  of  woman.  40  years  old,  who  had 
been  treated  unsuccessfully  with  arsenic. 
The  action  of  the  heart  was  tumultuous 
and  the  pulse-rate  was  160.  The  tremor 
in  the  hands  Avas  so  pronounced  as  to 
prevent  the  patient's  continuance  of 
work     as     a     sewing-machine    operator. 


The  woman  received  from  a  friend  120 
tablets  of  thvroid  extract,  each  of  10 
grains,  and  took  six  of  these  daily. 
After  the  lapse  of  three  months  the 
patient  appeared  almost  entirely  well. 
Slight  struma  was  still  discernible,  but 
exophthalmos  and  Graefe's  sign  had  dis- 
appeared; the  pulse  ranged  from  90  to 
96;  the  tremor  in  the  hands  was  absent; 
and  the  roaring  over  the  heart  was  no 
longer  apparent.  The  patient  herself  felt 
perfectly  well.  Silex  (Berliner  klin. 
Woch.,  No.  6,  '96). 

Case  apparently  much  benefited  by  the 
administration  of  thyroid  extract.  The 
case  had  existed  for  a  number  of  years, 
and  thyroid  enlargement  has  been  quite 
distinct.  After  the  thyroid  extract  had 
been  given  for  about  a  week,  the  pulse 
had  dropped  from  110  to  80,  and  ever 
since  then  the  patient  has  been  much 
more  comfortable.  It  was  necessary, 
however,  to  take  thyroid  every  few 
months.  There  had  been  no  return  of 
the  enlargement  except  for  a  few  days, 
while  the  patient  had  had  a  cold.  Hal- 
lock  (Jour.  Nerv.  and  Mental  Dis.,  June, 
'96). 

In  fiftj'-one  cases  of  exophthalmic 
goitre,  treated  by  the  thyroid  extract, 
the  size  of  the  gland  has  been  dimin- 
ished, but  the  other  symptoms  have  not 
been  relieved.  Crary  (Jour.  Nerv.  and 
Mental  Dis.,  June,  '96). 

Case  made  very  much  worse  by  the 
thyroid  extract.  Leszynsky  (Jour.  Nerv. 
and  Mental  Dis.,  June,  '96). 

Four  cases  showing  that,  while  thyroid 
extract  has  certainlj'  accomplished  a  cure 
in  two  of  the  eases,  the  indications  are 
strongly  against  its  indiscriminate  use 
in  exophthalmic  goitre.  It  acted  bene- 
ficially in  the  two  cases  and  injuriously 
in  the  two  others.  Its  cautious  exhibi- 
tion, in  proper  cases,  however,  is  not  to 
be  discouraged.  Henry  L.  Winter  (Araer. 
Medieo-Surg.  Bull.,  July  11,  '96). 

A  case  of  exophthalmic  goitre  success- 
fully treated  by  thyroidin.  Owing  to 
anorexia  and  nausea,  was  obliged  to  sus- 
pend the  treatment  three  times,  and  to 
reduce  the  dose,  but  after  about  sixty 
days  all  signs  of  the  disease  had  disap- 
peared.    A  year  later  the   patient   was 


ANIMAL  EXTRACTS.     THYROID.     GOITRE. 


377 


well,  cheerful,  and  bright,  and  her  men- 
strual functions  are  regular.  R.  M. 
Whitefoot  (Med.  News,  Get.  3,  '96). 

Case  of  a  girl  of  13  years  whose  father 
had  been  an  epileptic  and  whose  sister 
had  died  of  tubercular  meningitis. 
Marked  exophthalmos;  pulse,  140;  thy- 
roid gland  perceptibly  enlarged.  Usual 
means  having  failed,  resort  had  to  desic- 
cated thyroid,  5  grains  after  meals. 
After  two  days  considerable  relief.  On 
the  ninth  day  the  powders  gave  out  and 
in  two  days  the  pain  returned.  After 
five  months  of  treatment,  exophthalmos 
and  thyroid  enlargement  greatly  reduced, 
and  patient  comparatively  well.  Kerley 
(Pediatrics,  June  1,  '97). 

Thyroid  extract  given  in   case  of  ex- 
ophthalmic goitre  in  which  sudden  swell- 
ing of  the  gland  was  so  severe  as  to  in- 
terfere with  breathing;    also  in  a  case  of 
acute    thyroiditis.      In    both    cases    the 
swelling   subsided    and    symptoms   were 
relieved.     J.   Eliot    (Va.   Medical   Semi- 
monthly, June  28,  '98). 
Goitre. — In  simple  goitre  the  prepa- 
rations of  thyroid  prove  effective  in  about 
two-thirds  of  the  cases,  the  results  rang- 
ing from  total  disappearance  of  the  goitre 
to    a    noticeable   reduction   in    its    size. 
Children  and  young  adults  are  benefited 
in  the  great  majority  of  instances.     A 
favorable  result  is  seldom  obtained  in 
adults.    Increasing  doses  seem  to  procure 
the  most  satisfactory  effects.    The  influ- 
ence of  the  remedy  is  felt  after  the  first 
three  or  four  da3's  in  successful  cases, 
and,  in  a  month  or  so,  the  reduction  of 
an   average   tumor  will   generally   have 
been   effected.      In    order   to   keep    the 
goitre  from  returning,  the  administra- 
tion of  the  remedy  must  be  continued, 
the  preparation  being  given  in  reduced 
quantities  and  at  longer  intervals. 

The  results  have  been  practically  the 
same  whether  fresh  or  desiccated  glands 
or  extract  were  employed.  Its  admin- 
istration should  be  carefully  watched, 
however,  and  the  dose  reduced  upon  the 
appearance  of  any  untoward  symptom. 


Six  insane  patients  with  goitre  treated 
surreptitiously,  using  raw  thyroid  from 
the  sheep,  1 V2  or  1 V,  drachms  concealed 
in  slices  of  sausage  in  a  sandwich,  re- 
peated in  ten  or  fifteen  days.  In  five 
cases  there  was  an  appreciable  diminu- 
tion in  the  size  of  the  goitre  after  each 
ingestion  of  thyroid.  No  untoward 
symptoms.  Emminghaus  and  Reinhold 
(Les  Nouveaux  RemSdes,  No.  18,  '94). 

Nineteen  patients  treated  with  tablets, 
but  in  no  case  did  the  goitre  disappear 
entirely.  The  gland  sometimes  became 
smaller,  but  not  unless  the  patient  was 
young,  and  the  effect  was  only  tempo- 
rary. Ewald  (Berliner  klin.  Woch.,  Feb. 
3,  '95). 

Ninety-three  patients  treated  partly 
with  an  extract  of  fresh  thyroid  glands 
of  wethers  and  partly  with  thyroid  tab- 
lets. In  twenty-five  cases  glands  of 
freshly  slaughtered  animals  reduced  to  a 
pulp  and  mixed  with  water  were  used 
exclusively,  the  average  quantity  taken 
by  a  patient  in  a  week  being  5  drachms, 
although  in  some  cases  it  rose  to  9 
drachms.  In  the  hot  season  the  patient 
complained  of  slight  gastric  troubles, 
which,  however,  disappeared  as  soon  as 
the  thyroid  preparation  was  preserved  in 
ice.  There  was  only  one  instance  in 
which  the  treatment  had  to  be  discon- 
tinued on  account  of  its  disagreeing  with 
the  patient.  The  thyroid  gland  regained 
its  normal  dimensions  in  only  four  of  the 
twenty-five  patients  treated  in  this  way, 
and  in  only  two  of  these  four  was  the 
good  effect  permanent,  for  the  other  two 
had  a  relapse  after  the  expiration  of  a 
month.  In  all  the  other  cases  there  was 
an  obvious  reduction  in  the  size  of  the 
gland,  and  with  two  of  the  patients  this 
was  permanent,  but  it  generally  began 
to  swell  again  whenever  the  treatment 
was  stopped.  The  frequency  of  the  pulse 
was  a  little  augmented,  but  never  so 
much  as  to  make  an  interruption  of  the 
treatment  necessary.  A  number  of  pa- 
tients after  having  taken  the  fresh  glands 
for  several  weeks  were  then  treated  by 
tablets.  In  another  series  these  tablets 
were  used  from  the  beginning  of  the 
treatment.  The  results  were  much  less 
satisfactory.  Stabel  (Berliner  klin. 
Woch.,  Feb.  3,  '95). 


378 


ANIMAL  EXTRACTS.     THYROID.     GOITRE. 


Sixty  cases  of  benign  parenchymatous 
goitre,  without  selection,  treated  with 
thyroid  tabloids^  2  daily  to  adults,  1  to 
children.  Duration  of  treatment  from 
three  to  four  weeks,  on  the  average.  In 
young  children  complete  recovery  the 
rule.  In  adults  recovery  rare  and  less 
common  in  proportion  to  age.  Complete 
return  of  thyroid  to  normal  size  not  to 
be  expected  later  than  twentieth  year. 
Bruns  (Anier.  Jour.  Med.  Sciences,  May, 
'95). 

Warning  against  too  sanguine  views  as 
to  success  of  thyroid  treatment.  Kocher 
(London  Lancet,  July  20,  '95). 

Cases  treated  by  desiccated  thyroids. 
Size  rapidly  reduced,  though  treatment 
not  maintained  for  a  sufficient  time  to 
establish  final  recovery.  Remedy  not  free 
from  danger  if  given  in  unlimited  quan- 
tities and  over  too  great  a  length  of 
time.  Illustrative  case.  E.  Fletcher  In- 
gals   (Medicine,  Aug.,  '95). 

Among  twenty-one  cases  of  goitre,  in 
eleven,  of  from  2  to  17  years  of  age,  there 
was  considerable  diminution,  but  not 
complete  disappearance,  of  the  tumor;  in 
five,  from  12  to  21  years  of  age,  the  amel- 
ioration was  slight,  and  in  five  cases  there 
was  no  result.  Knopfelmacher  (Wiener 
klin.  Woch.,  Oct.  10,  '95). 

[In  a  case  of  goitre  under  my  care,  in 
which  thyroid  tablets  were  given,  the 
latter  had  to  be  discontinued  on  account 
of  untoward  symptoms:  accelerated  and 
weak  pulse  with  tendency  to  syncope, 
accelerated  respiration  with  dyspnoea, 
increased  diuresis,  and,  also,  pronounced 
anorexia,  which  disappeared  upon  the 
withdrawal  of  the  thyroid  extract.  C. 
Sumner  Wtthebstine,  Assoc.  Ed.,  An- 
nual, '96.] 

Nine  children  suflering  from  parenchy- 
matous goitre  healed  with  Merck's  tab- 
loids containing  5  grains  of  thyroidin. 

Children  under  two  had  from  Vs  to  I 
tabloid  daily  during  the  first  week,  and 
from  1  to  2  tabloids  daily  afterward; 
older  children,  after  the  first  week,  as 
many  as  4  or  5  tabloids  allowed  daily. 
Marked  diminution  in  the  size  of  the 
gland,  the  improvement  commencing 
after  about  three  days'  treatment  and 
reaching  its  maximum  in  three  weeks. 

In  all  the  eases  treated  the  rapidity  of 


the  heart's  action  was  increased;  but, 
on  the  discontinuance  of  treatment,  the 
action  again  became  normal.  Cautious 
use  of  the  drug  advised,  beginning  with 
small  doses,  and  gradually  increasing 
them.  If  the  heart's  action  becomes 
irregular,  suspension  of  treatment.  Do- 
browsky  (Arch.  f.  Kinderh.,  B.  26,  '96). 

Seventy-eight  cases  treated  with  thy- 
roid. In  all  the  cases  in  which  the  treat- 
ment was  tolerated  and  continued  for 
several  weeks,  diminution  of  the  goitre 
was  attained.  Best  results  noticed  in  the 
soft,  simple,  hyperplastic  goitres,  espe- 
cially in  those  occurring  about  the  age 
of  puberty.  Cystic  goitres  became  more 
superficial  through  the  atrophy  of  the 
hyperplastic  tissues,  and  their  enuclea- 
tion was  facilitated.  Angerer  (Mun- 
chener  med.  Woch.,  p.  93,  '96). 

Thyroid  gland  is  best  adapted  for  the 
form  known  as  struma  parenehymatosa. 
Definite  cure  is  rarely  observed  and  only 
in  young  subjects.  The  results  are  satis- 
factory in  63  per  cent,  of  cases,  the  goitre 
lessening  in  size.  In  30  per  cent,  of  the 
eases  the  treatment  is  absolutely  value- 
less. When  goitre  has  undergone  sec- 
ondary degenerations,  such  as  colloid  or 
cyst-  formation,  the  treatment  is  useless. 
Serafine  (Revue  de  Ther.,  July  15,  '97). 

Case  of  weak,  cachectic  newborn  infant 
presenting  a  marked  bilobed  goitre.  The 
mother,  herself  goitrous,  was  in  excellent 
health,  but  mentally  weak.  The  treat- 
ment of  the  mother  consisted  in  daily 
administration  of  22  ^/j  grains  of  thyroid 
body.  At  the  end  of  one  month  and  a 
half  her  goitre  had  almost  totally  dis- 
appeared, and  in  the  infant  the  cure  was 
complete.  MossS  (Revue  Men.  des  Mai. 
de  I'Enfance,  June,  '98). 

Thyroidism  in  an  infant  from  adminis- 
tration of  thyroid  extract  to  the  mother, 
a  woman,  aged  34,  who  had  exophthalmic 
goitre.  On  December  24th  thyroid  ex- 
tract (two  5-grain  tabloids  daily)  was 
administered  to  the  mother.  On  January 
1st  the  child  had  been  sweating  profusely 
for  several  nights.  It  was  looking  ill 
and  was  sleepless.  It  had  vomited  every 
morning  for  three  days.  The  extract 
was  consequently  stopped  for  five  days. 
The  child  immediately  improved,  and  on 
January   4th   was   quite   well.     On    the 


ANIAL-VL  EXTRACTS.     THYROID.     INSANITY. 


379 


ninth  thyroid  extract  was  again  given  to 
the    mother.     The    next   day   the    child 
vomited,  was  again  restless,  did  not  look 
well,   and   sweated   profusely,   etc.     The 
child  was  weaned  and  after  this  remained 
perfectly  well.     Byrom  Bramwell    (Lan- 
cet, Mar.  18,  '99). 
Insanity. — It  is  in  melancholia  and 
the  mental  disorders  connected  with  the 
menopause  that  thyroid  extract  finds  its 
greatest  usefulness.    In  recurrent  mania, 
delusional  insanity,  excellent  results  have 
also  been  reported.    MacPhail  and  Bruce 
consider  its  itse   dangerous  in  cases  of 
acute  mania  and  melancholia  where  there 
are  rapid  loss  of  body-weight  and  mal- 
assimilation  of  food;  also  in  cases  where 
there  is  active  phthisis  or  valvular  disease 
of  the  heart.     The  profoimd  effects  of 
the  drug  on  the  circulatory  system  render 
it  imperative  that  during  treatment,  and 
for  at  least  a  week  afterward,  the  patient 
should  be  rigorously  confined  to  bed. 

Oskr  is  of  the  opinion  that  the  cases 
of  insanity  in  which  thyroid  extract 
proved  beneficial  were  probably  cases  in 
which  there  was  some  derangement  of 
the  thyroid  gland.  The  pulse  ran  up 
under  its  influence  in  some  cases  to  160, 
but  in  none  had  it  caused  any  serious 
results. 

Kinnicutt,  in  sustaining  this  view, 
thinks  that  the  very  fact  that  in  a  large 
majority  of  the  cases  the  treatment  is 
without  effect,  while  now  and  then  it  is 
so  strikingly  successful,  would  indicate 
that  in  the  latter  the  trouble  was  prob- 
ably connected  with  diminished  or  per- 
Terted  secretion  or  function  of  the  thy- 
roid gland.  As  in  other  disorders,  the 
use  of  thyroid  has  to  be  continued  after 
recovery  to  prevent  relapse. 

In  twenty-five  cases  internal  adminis- 
tration of  thyroid  induced  true  febrile 
process;  resulting  action  beneficial.  Spe- 
cially useful  in  insanity  of  adolescent, 
climacteric,  and  puerperal  periods,  and 
frequently    so    in    cases    where    recovery 


is  protracted  and  tendency  is  to  drift 
into  dementia.  Bruce  (Jour,  of  Mental 
Science,  Jan.,  '95). 

Four  cases  of  insanity  with  well- 
marked  stupor  where  the  outlook  had 
become  unfavorable,  if  not  hopeless.  A 
decided  reaction  sought  for,  and  the  dose 
of  thyroid  regulated  by  the  tolerance  of 
each  patient.  No  benefit  in  one  case; 
two  sufficiently  benefited  to  be  dis- 
charged from  the  asylum,  and  a  fourth 
materially  improved.  Cell-nutrition  is 
undoubtedly  afl'ected  in  a  striking  man- 
ner, and  increased  metabolism  occurs  as 
the  result  of  quickened  circulation.  The 
autotoxie  process,  so  frequently  present 
in  cases  of  mental  disease,  is  interfered 
with  in  a  way  that  may  be  beneficial. 
C.  K.  Clark  (Canadian  Pract.,  Oct.,  '95). 

Cases  of  post-melancholic  hebetude  fol- 
lowing a  lengthy  period  of  depression 
offer  the  best  prospect  of  improvement 
and  are  more  or  less  influenced  in  the 
majority  of  instances. 

Cases  of  stuporous  melancholia  of  long 
duration  are  usually  improved  by  thy- 
roid. Cases  which  recover  appear  to  have 
a  special  predilection  to  relapse. 

Maniacal  cases  Avhose  attacks  have 
been  unduly  prolonged  give  a  very  en- 
couraging prognosis. 

Cases  of  cerebral  exhaustion  following 
acute  delirium  or  stupor  whose  elimina- 
tion of  urea  and  other  nitrogenous  com- 
pounds is  greatly  reduced,  offer  a  fair 
chance  of  improvement. 

Many  cases  of  chronic  mania  without 
fixed  delusions  may  be  benefited  by  a 
course  of  thyroid  treatment. 

In  doubtful  cases  thyroid  may  assist 
in  clearing  up  the  diagnosis.  It  will 
early  differentiate  between  true  stupor 
and  dementia.  In  delusional  cases  of  a 
doubtful  nature  a  course  of  treatment 
will  usually  show  whether  delusions  are 
fixed  or  temporary,  as  the  latter  will 
vary  in  character  or  entirely  disappear 
during  treatment,  while  the  former  un- 
dergo no  change  whatever.  W.  L.  Bab- 
cock  (State  Hosp.  Bull.,  Utiea,  K.  Y., 
Jan.,  '96). 

The  early  use  of  the  thyroid  and  treat- 
ment of  forms  of  insanity  not  associated 
with   myxoedema   appears  to   have  been 


380 


ANIJIAL  EXTRACTS.    THYROID.    INSANITY. 


based  upon  observations  made  in  the  use 
of  thyroid  in  other  conditions,  showing 
that  a  mild  febrile  reaction  follows  the 
employment  of  the  gland.  It  was  to 
induce  this  febrile  reaction  that  first  sug- 
gested the  employment  of  the  thyroid  in 
non-myxoeaematous  cases  of  insanity. 

Case  characterized  by  delusions  of 
doubt  and  fear,  especially  of  fear  of  con- 
tamination, improved.  Better  control 
over  most  of  the  ideas  of  contamination. 

Case  of  chronic  delusional  insanity, 
violent,  untidy,  destructive,  with  rough 
skin  and  scanty  hair,  rapidly  improved. 

Case  of  a  mild  case  of  simple  melan- 
cholia with  slight  enlargement  of  the 
thyroid  gland;  at  first  more  depressed, 
but  now  convalescent. 

Case  with  attacks  of  recurrent  mani- 
acal excitement.  At  first  evident  eleva- 
tion of  temperature,  flushed  face,  free 
perspiration,  and  slight  nausea.  Patient 
practically  convalescent. 

Two  cases  of  chronic  melancholia  in 
men  in  which  no  improvement  was  mani- 
fest. 

Inclined  to  indorse  the  views  of  Bruce, 
that  the  thyroid  undoubtedly  produced 
a  more  or  less  feverish  condition,  the 
action  and  reaction  to  which  are  of  con- 
siderable benefit  to  the  patient.  Thyroid 
is  a  direct  cerebral  stimulant,  and  there 
is  a  strong  probability  that  at  some 
periods  of  life  the  administration  of  thy- 
roid supplies  some  substances  necessary 
to  the  bodily  economy.  E.  N.  Brush 
Jour,  of  Nerv.  and  Mental  Dis.,  Apr., 
'96). 

One  very  important  function  of  the 
thyroid  is  to  stimulate  brain-metabolism. 
We  must  regard  the  thyroid  extract  as 
containing  a  most  potent  cerebral  stim- 
ulant which  does  alter,  in  some  way,  the 
metabolism  of  the  nerve-centres  and 
stimulates  them  in  a  most  extraordinary 
manner.  William  Osier  (Jour,  of  Nerv. 
and  Mental  Dis.,  Apr.,  '96). 

Forty  cases,  consisting  chiefly  of  com- 
mencing senile  dementia,  acute  mania, 
and  melancholia,  treated  with  thyroid. 
Of  these,  eight  were  unaffected  by  the 
treatment,  twelve  were  somewhat  and 
fourteen  were  much  improved,  five  cured, 
and   one  died.     The   drug  had  an   alto- 


gether extraordinary  influence  on  the 
mental  condition  of  the  patients.  Among 
clinical  symptoms  during  the  use  of  the 
remedy,  rise  of  temperature  and  pulse- 
rate,  gastric  disturbances,  increased  per- 
spiration and  quantity  of  urine,  transient 
albuminuria  in  10  per  cent.,  cedema  of 
face  and  extremities,  cyanosis,  desquama- 
tion of  the  skin^  sexual  excitement, — so 
that  masturbation  in  three  cases  necessi- 
tated the  discontinuance  of  the  thyroid 
extract, — were  observed.  C.  G.  Hill 
(Trans.  Med.  and  Chir.  Fac,  Maryland, 
p.  30,  '96). 

Thyroid  treatment  of  great  value  in  a 
form  of  mental  disturbance  occurring  at 
the  climacteric:  a  mental  depression 
with  anxiety  and  morbid  fears,  but  with- 
out delusions  of  insomnia.  Allen  Starr 
(Amer.  Jour.  Med.  Sci.,  vol.  cxiv.  No.  1, 
'97). 

Insane  cases  in  which  a  pill  containing 
5  grains  of  fresh  sheep's  gland  was  ad- 
ministered daily,  and  subsequently  in- 
creased to  two  or  three  according  to  re- 
sults. Besides  the  usual  symptoms  there 
^^■as  more  or  less  mental  or  motor  excite- 
ment in  all  cases  no  matter  how  de- 
pressed or  demented  the  patients  had 
been  previous  to  the  administration.  In 
some  instances  there  was  considerable 
mental  improvement.  Berkley  (Johns 
Hopkins  Hos.  Bull.,  July,  '97). 

In  conditions  marked  by  inhibition  of 
sensory,  motor,  and  mental  activity, 
without  gross  organic  lesion,  such  as 
obtain  in  catatonia  and  in  certain  types 
of  stuporous  insanity  and  melancholia, 
we  may  expect  beneflt  from  thyroid  med- 
ication, judiciously  used. 

Results  of  thyroid  feeding  in  twenty 
patients.  The  extract,  in  tabloids  of  5 
grains  each,  administered.  1.  Melan- 
cholia agitata.  Four  females  and  one 
male.  The  four  females  were  unim- 
proved, the  male  greatly  benefited.  2. 
Melancholia.  Three  females  and  four 
males.  The  females  and  all  but  one  of 
the  males  Avere  unimproved.  3.  Senile 
dementia.  One  female.  No  improvement 
under  treatment.  4.  Chronic  mania. 
Two  females.  No  improvement  under 
treatment.  5.  Mental  enfeeblement.  One 
female  and  two  males.    No  improvement 


ANIMAL  EXTllACTS.     THYROID.     INSANITY. 


381 


under  treatment.  6.  Dementia.  One 
female  and  one  male.  No  improvement 
under  treatment.  In  all  cases  the  pulse 
was  the  first  to  show  any  change,  and 
was  most  affected  by  the  drug.  Robert 
Cross  (Edinburgh  Med.  Jour.,  Nov.,  '97). 

Results  of  administration  of  thyroid 
extract  on  the  red  and  white  corpuscles 
and  haemoglobin  in  cases  of  anaemia  as- 
sociated with  melancholia.  In  9  eases 
thyroid  medication  was  employed  and  in 
5  cases  there  was  a  marked  change  for 
the  better;  in  the  other  no  favorable  in- 
fluence was  noted.  In  3  of  the  5  in 
which  improvement  took  place  there  was 
increase  of  weight  during  the  treatment, 
and  in  2  subsequently.  The  psycholog- 
ical effect  was  observed  almost  from  the 
beginning  in  those  in  which  permanent 
improvement  took  place.  Samuel  Bell 
(Phila.  Med.  Jour.;  Brit.  Med.  Jour., 
July  9,  '98). 

As  a  result  of  thyroid  treatment  in 
1032  collected  cases  of  insanity,  the  fol- 
lowing conclusions  reached:  1.  The  dose 
of  the  extract  depends  entirely  on  the 
individual  case.  In  some  eases  25  gi'ains 
three  times  a  day  will  be  necessary  to 
bring  abOut  a  circulatory  or  temperature 
reaction,  while  in  others  the  same  results 
may-  be  had  with  the  use  of  5  grains 
t.  i.  d.  Each  case  must  be  a  law  unto 
itself.  2.  It  is  essential  that  the  patient 
should  be  placed  in  bed  to  obtain  the 
best  results,  and  he  should  be  continued 
there  during  the  entire  treatment  and 
for  a  week  following  its  discontinuance. 
3.  The  treatment  should  be  continued  for 
at  least  thirty  days.  4.  We  should  not 
be  discouraged  by  failure  in  the  first  ad- 
ministration, but  should  resort  to  two, 
three,  or  more  trials,  if  necessary.  5. 
The  most  gratifying  results  in  thyroid 
treatment  are  to  be  obtained  in  eases  of 
acute  mania  and  melancholia  with  pro- 
longed attacks,  puerperal  and  climacteric 
insanities,  stuporous  states  and  primary 
dementia,  particularly  where  these  forms 
of  mental  alienation  do  not  respond  to 
the  usual  methods  of  treatment.  6.  A 
high  temperature  reaction  is  not  essen- 
tial, as  the  average  maximum  tempera- 
ture in  the  recovered  cases  among  men 
was  99.6°.  7.  Physical  improvement  is 
the  outcome  in  most  cases  whether  men- 


tal improvement  takes  place  or  not.  8. 
The  proportion  of  individuals  who  re- 
cover under  thyroid  treatment  and  then 
relapse  is  less  than  the  proportion  that 
relapse  after  recovery  from  other  meth- 
ods of  treatment.  In  personal  series  of 
cases  only  one  patient  who  recovered  has 
relapsed.  William  ilabon  and  Warren 
L.  Babcock  (Amer.  Jour,  of  Insanity, 
Oct.,  '99). 

Trial  of  thyroid  in  130  patients  whose 
insanity  was  definitely  making  no  prog- 
ress toward  recovery  under  the  methods 
adopted  in  the  asylum,  or  whose  insanity 
was  becoming  chronic  or  incurable.  Each 
patient  was  put  to  bed  during  the  period 
of  experiment,  and  was  given  a  staple 
diet  sufficient  to  maintain  body-weight  at 
its  usual  level,  the  administration  of 
the  extract  beginning  on  the  fifth  day. 
The  patient  was  weighed  weekly  during 
treatment  and  for  a  month  after.  The 
urine  was  regularly  examined  and  the 
urea  was  estimated  by  the  hypobromite 
method.  The  phosphates  in  the  urine 
were  determined  by  the  uranium  method. 
The  thyroid  extract  was  administered  in 
130  cases  of  insanity  (45  males  and  85 
females)  with  the  following  results: 
T^Tiere  large  doses  were  given  there  fol- 
lowed pyrexia  in  most  of  the  cases  to  a 
slight  or  moderate  degree.  Loss  of 
weight  was  a  constant  symptom,  also 
increased  sweating,  pains,  and  tinglings 
in  various  parts  of  the  body,  and  a  slight 
or  moderate  degree  of  exaltation,  or  rest- 
lessness. There  was  tachycardia  in  most 
cases,  and  the  respirations  were  increased 
by  about  six  per  minute.  Appetite  and 
thirst  increased,  and  in  females  menstru- 
ation was  made  more  profuse  than  usual. 
Urea  and  nitrogenous  products  were  in- 
creased in  the  urine,  showing  an  en- 
hanced metabolic  activity.  Slight  transi- 
tory albuminuria  was  found  in  10  per 
cent,  of  the  cases.  In  moderate  and 
small  doses  the  above  results  were  pres- 
ent in  a  correspondingly  less  degree,  and 
it  was  concluded  that  the  thyroid  ex- 
tract acted  as  a  powerful  metabolic 
(katabolic)  stimulant.  The  patients  in- 
cluded five  idiots  and  imbeciles,  seven 
pubescent  or  adolescent  cases,  and  cases 
of  mania,  melancholia,  myxoedema,  alco- 
holic and  general  paralytic  insanity,  etc. 


382 


ANIMAL  EXTRACTS.    THYROID.     MYXOEDEMA. 


Of  a  total  of  130  patients,  12  recovered, 
29   were   improved,   and  89   were   unim- 
proved.    The  recoveries  included  4  eases 
of  stupor,  3  of  puerperal  mania,  1  of  lac- 
tational melancholia,  1  of  myxoedema,  1 
of  simple  melancholia,  and  2  of  climac- 
teric  melancholia.     These   patients   also 
improved    physically.      The    threatened 
attacks  of  foUe  ciroulaire  were  aborted 
by  thyroid  administration.    C.  C.  Easter- 
brook   (Lancet,  Aug.  25,  1900). 
Myxcedbma.  —  With  very  few  excep- 
tions,  cases   of  myxcedema   are   always 
attended  by  well-marked  atrophy  of  the 
thyroid  gland.     That  the  disease  is  a 
result  of  the  absence  from  the  blood  of 
the  secretion  of  the  thyroid  is  a  logical 
conclusion  which  the  use  of  the  gland 
as  a  remedy  has  amply  verified.     Again, 
the  fact  that  absence  of  the  gland  is  the 
primary  factor  in  the   etiology  of  the 
disease  also  makes  it  plain  that  unless 
the  secretion  which  it  furnishes  the  sys- 
tem is  replaced  continuously  the  disease 
will  recur  after  recovery:    another  fact 
verified  by  practical  experience,  which 
has  shown  that  small  doses  of  the  gland 
must  be  administered  for  years  if  the 
recurrence  of  the  myxredemic  symptoms 
is  to  be  prevented. 

As  originally  recommended  by  Mur- 
ray, the  treatment  should  be  divided  into 
two  stages:  (1)  removing  the  symptoms 
of  the  disease;  (2)  maintaining  the  con- 
dition of  health  attained.  The  first  stage 
must  be  carried  on  gradually,  and  with 
care,  as  the  alteration  in  the  patient's 
condition  is  so  great  that,  in  many  cases, 
it  is  not  safe  to  bring  it  about  rapidly. 
This  caution  applies  especially  to  cases 
which  show  signs  of  cardiac  or  vascular 
degeneration.  Several  such  patients  have 
died  of  syncope  brought  on  by  overexer- 
tion, after  the  symptoms  of  myxoedema 
had  been  much  improved.  Ten  to  15 
minims  of  the  extract,  twice  or  thrice  a 
week,  may  be  slowly  injected.  If  flush- 
ing of  the  face  or  pain  in  the  lumbar 


region  occur,  the  injection  should  be 
stopped.  When  taken  by  the  mouth 
from  the  beginning,  daily  doses  of  5  to 
]5  minims  two  or  three  hours  after 
breakfast  have  been  found  best.  The 
changes  which  take  place  in  the  tem- 
perature, pulse,  weight,  appearance,  and 
sensations  of  the  patient  are  all  impor- 
tant in  governing  the  dose.  In  the  sec- 
ond stage,  the  smallest  dose  which  keeps 
the  temperature  up  to  the  normal,  or 
above  97°  F.,  is  sufficient.  The  remedy 
is  given  preferably  by  the  mouth  in  this 
stage. 

AVhen  cardiac  disorders  are  present, 
the  dose  should  be  small  and  the  patient 
kept  in  the  recumbent  position,  as  ad- 
vised by  Bramwell. 

Two  deaths,  under  treatment,  of  pa- 
tients with  weak  heart.  F.  Vermehren 
(Centralb.  f.  Nerv.  Psy.,  etc.,  July,  '93). 
The  dose  should  be  much  smaller  when 
cardiac  disorders  are  present  than  the 
usual  one.  Complete  rest  in  the  recum- 
bent position  should  be  enforced  from  the 
commencement  of  the  treatment.  B. 
Bramwell  (Practitioner,  July,  '93). 

Effect  of  thyroid  extract  in  myxoe- 
dema complicated  by  angina  pectoris 
beneficial.  No  discomfort  until  the 
twelfth  day,  when  extract  discontinued. 
H.  C.  L.  Morris  (Lancet,  Sept.  28,  '95). 

Statistics  of  one  hundred  and  sixteen 
cases,  with  absolute  failure  to  secure  im- 
provement in  only  three,  show  the  value 
of  the  thyroid  treatment.  Eeports  vary 
in  regard  to  the  degree  of  improvement 
from  "cure"  to  "slight  improvement." 
The  latter  cases,  however,  were  few  in 
number.     (Eskridge.) 

Case  of  myxoedema  placed  on  a  diet 
regulated  so  that  its  different  elements 
should  be,  as  far  as  possible,  the  same 
each  day.  At  the  end  of  a  week  treat- 
ment with  thyroid  extract  was  begun, 
the  diet  remaining  the  same.  During 
treatment  the  urine  was  increased  in 
volume;  the  nitrogen  excreted  in  the 
urine    exceeded    the    total    quantity    of 


ANIMAL  EXTRACTS.    THYROID.    MYXCEDEMA. 


383 


nitrogen  in  the  food,  and  appeared  in 
the  urine  chiefly  in  the  form  of  urea. 
Phosphoric  acid  and  chlorine  elimination 
was  practically  unafl'ected.  The  body- 
weight  was  diminished  rapidly  and  the 
temperature  raised.  Mental  improve- 
ment in  myxcedematous  patients  under 
the  thyroid  treatment  has  generally  been 
as  marked  as  the  physical.  W.  M.  Ord 
and  E.  White  (Brit.  Med.  Jour.,  July  29, 
'93). 

Eleven  cases  of  myxoedema  treated  by 
thyroid  grafting.  Improvement  in  six 
and  failure  in  five  cases.  Kinnicutt 
(Med.  Record,  Oct.  7,  '93). 

Case  of  a  boy,  about  5  years  of  age, 
who,  in  the  early  part  of  the  treatment, 
took  one-fourth  of  the  thyroid  gland  of 
a  sheep  each  twenty-four  hours.  Later 
on  the  gland  was  given  him  in  a  desic- 
cated form.  In  fourteen  months  the  boy 
grew  four  inches:  an  unusual  increase. 
At  the  time  of  the  report  he  walked  and 
ran  about,  and  had  gained  so  much  men- 
tally that  few  would  think  him  abnor- 
mal in  this  particular.  Osier  (Med. 
Record,  July  21,  '94). 

Three  cases  of  myxoedema  in  which 
fresh  thyroid  gland  was  given.  Results 
excellent,  but  temporary.  If  moderate 
doses  be  given,  the  symptoms  character- 
istic of  goitre  can  be  made  to  disappear 
gradually.  W.  Pasteur  (Rev.  Med.  de  la 
Suisse  Rom.,  p.  35,  '94). 

Unmistakable  improvement  in  three 
eases  of  myxoedema.  Good  results  from 
the  use  of  the  tabloids  containing,  each, 
5  grains  of  the  extract.  Starr  (Boston 
Med.  and  Surg.  Jour.,  Sept.  27,  '94) . 

Two  cases  of  myxoedema  in  children, 
one  a  girl  9  years  old,  the  other  a  boy 
12  years  old,  treated  with  glycerin  ex- 
tract of  sheep's  thyroid.  Improvement. 
Northrup  (Archives  of  Pediatrics,  Nov., 
'94). 

In  a  ease  of  congenital  myxoedema 
treated  with  thyroid,  diameter  of  red 
corpuscles  before  treatment  began  was 
3.13  microns;  after,  it  was  7.5  microns. 
Nucleated  red  corpuscles  disappeared 
under  treatment.  Persistence  of  a  foetal 
state  of  blood  seems  to  coincide  with  a 
tardy  development  of  the  body.  Lebre- 
ton  and  Vaquez  (La  France  M6d.  et  Paris 
M6d.,  Jan.  18,  '95). 


The  treatment  of  acquired  myxoedema 
in  the  adult  is  almost  universally  suc- 
cessful. When  failure  occurs,  it  is  gener- 
ally in  experienced  hands  or  the  thyroid 
itself  is  not  good.  For  a  continuous  good 
result  treatment  must  be  maintained, 
but,  as  the  action  of  thyroid  is  cumu- 
lative, intervals  of .  cessation,  varying  in 
different  cases,  are  necessary.  In  winter 
larger  doses  and  shorter  intervals  are 
necessary  than  in  summer.  Feeling  of 
cold  an  indication  to  renew  treatment. 
One  grain  of  powder  cautiously  increased. 
Meltzer  (Amer.  Medico-Surg.  Bull.,  July 
1,  '95). 

Several  children  suffering  from  myxce- 
dematous idiocy,  in  whom  physical  and 
intellectual  conditions  were  greatly  bene- 
fited by  thyroid  alimentation.  Bourne- 
ville  (Revue  de  Ther.  Medico-Chir.,  Nov. 
1,  '95). 

Sixteen  cases  of  myxoedema  treated 
with  thyroid  gland,  in  two  of  which 
exact  estimates  of  metabolic  processes- 
made,  metabolism  of  proteids  found  to 
be  excessively  small,  proteids  of  food 
digested  in  a  defective  manner;  when 
thyroid  ingested,  more  nitrogen  excreted, 
and  whole  metabolism  improved.  Ver- 
mehren   (Univ.  Med.  Jour.,  Nov.,  '95). 

After-history  of  the  first  case  of  myx- 
osdema  treated  by  thyroid  extract.  The 
patient,  a  woman  aged  46,  who  had  suf- 
fered from  myxoedema  four  or  five  years- 
before  the  treatment  was  commenced  in 
April,  1891,  is  still  quite  free  from  the 
disease.  On  two  occasions,  when  the 
remedy  was  discontinued  for  some  time,, 
the  symptoms  partly  returned.  She  still 
takes  1  drachm  of  thyroid  extract  each 
week.  C.  R.  Murray  (Brit.  Med.  Jour.^ 
Feb.  8,  '96). 

Series  of  cases,  some  of  which  had  beea 
under  continual  and  regular  treatment, 
others  in  which  the  treatment  by  thyroid 
extract  had  been  irregular  and  intermit- 
tent. The  cases  in  which  the  treatment, 
had  been  continual  had  lost  all  the  char- 
acteristic features  of  my.xoedema,  and: 
could  no  longer  be  recognized  as  in- 
stances of  that  disease.  Other  cases  in 
which  the  treatment  had  only  been 
irregularly  carried  out  still  presented 
characteristic  features  of  myxoedema. 
Myxoedemic     patients     taking     thyroid 


384 


ANIMAL  EXTRACTS.     THYROID.     MIDDLE-EAR  DISORDERS. 


preparations  complained  of  a  great  deal 
of  pain  in  tlie  baclt  or  limbs,  and  that 
it  was  worthy  of  consideration  whether 
those  pains  might  not  be  of  a  gouty 
nature.  Thomas  Harris  (Brit.  Med. 
Jour.,  Feb.  15/96). 

Priority  claimed,  as  regards  giving  the 
thyroid*  gland  by  the  mouth,  for  Dr. 
Howitz,  of  Copenhagen.  Polyuria,  rise 
of  temperature,  insomnia,  and  pains  in 
the  limbs  are  signs  warning  that  the 
remedy  should  be  suspended.  Dupaquier 
(New  Orleans  Med.  Jour.,  Mar.,  '96). 

Case  in  which,  after  treatment  by  ex- 
tract of  thyroid  for  six  weeks,  all  symp- 
toms had  disappeared  and  the  reduction 
of  the  weight  was  forty  pounds.  This 
method  of  treatment  does  not  influence 
favorably  cases  of  ordinary  obesity.  All 
cases  must  be  carefully  studied  and 
selected  before  this  powerful  agent  is  to 
be  administered.  J.  M.  Anders  (Med. 
and  Surg.  Reporter,  June  12,  '97).  (See 
Myxcedejia.) 

Where  the  total  removal  of  the  thy- 
roid has  been  practiced,  Billroth  observed 
no  onset  of  tetany  in  109  cases.  Weiss 
found  23  per  cent,  among  53  cases,  Roux 
none  in  118.  Eiselsberg,  Schiflf,  Wagner, 
and  Horsley  saw  symptoms  of  tetany  and 
of  chronic  convulsions  in  animals  de- 
prived of  a  more  or  less  large  portion 
of  the  thyroid  gland.  Tetanus  com- 
mences with  trismus,  and  thereafter  af- 
fects the  more  peripheral  muscles,  and  is 
remittent,  not  intermittent;  while  tetany 
first  affects  the  muscles  of  the  extremi- 
ties, never  beginning  in  the  masseters, 
and  is  always  of  an  intermittent  type. 
Schilling  (Miinchener  med.  Woch.,  Feb. 
21,  '99). 

Case    of    myxcedema    complicated    by 
mental  symptoms  in  w-hich   thyroid  ex- 
tract was   used   Avithout   effect   for   two 
months;     after    this    marked    and    con- 
tinued   improvement    occurred.      R.    R. 
Deeper  (Brit.  Med.  Jour.,  Jan.  27,  1900). 
Lactation. — In  the  various  disorders 
of    lactation    the    thyroid    preparations 
have  been  found  of  signal  service,  espe- 
cially as  galactagogues. 

Because  of  its  specific  action  upon  the 
mammary  glands,  thyroidin  is  of  great 
value  to  women  in  whom  lactation  is  im- 


perfect. Hertoghe  (Rev.  M6d-Chir.  des 
Maladies  des  Femmes,  June  25,  '96). 

Thyroid  extract  is  a  valuable  galac- 
tagogue;  it  stimulates  the  mammary 
secretion,  w'hile  it  lessens  functional 
activity  of  the  uterus.  Cheron  (Revue 
Medico-Chir.  des  Mai.  des  Femmes,  Nov. 
25,  Dec.  25,  '96). 

Two  cases  in  which  deficiency  of  milk 
was  counteracted  by  tabloids  of  thyroid 
gland.  In  one  of  these  the  milk  became 
free  while  tablets  were  being  taken,  and 
failed  as  soon  as  they  Avere  neglected. 
Stawell  (Intercolonial  Med.  Jour,  of 
Australasia,  Apr.  20,  '97). 

Extract  of  thyroid  gland  found  to  be 
an  efficient  galactagogue  in  certain  cases, 
and  the  milk  secreted  under  this  influ- 
ence found  to  be  of  good  nutritive  qual- 
ity. Stawell  (Intercolonial  Med.  Jour,  of 
Aus.;    Ther.  Gaz.,  Jan.  15,  '98). 

Middle-Eae  Disorders.  —  A  few 
myxcedematous  patients,  suffering  from 
deafness,  having  improved  in  hearing 
during  the  administration  of  thyroid  ex- 
tract, several  observers  gave  this  drug  a 
trial  in  chronic  adhesive  processes  of  the 
middle  ear  uncomplicated  with  myxce- 
dema. Various  results  have  been  ob- 
tained, success  or  non-success  evidently 
depending  in  a  marked  way  upon  the 
degree  of  thickening  and  ankylosis  that 
may  be  present.  On  the  whole,  thyroid 
is  not  of  much  value  in  aural  diseases. 

Results  obtained  in  a  number  of  pa- 
tients in  Politzer's  clinic,  commencing 
with  1  tabloid  daily,  and  increasing  them 
in  a  fortnight's  time  to  3  per  diem. 
After  four  weeks  of  treatment  the  drug 
was  discontinued  for  a  week,  and  again 
resumed.  No  bad  symptoms  observed. 
At  first  marked  impairment  in  hearing, 
both  to  loud  speech  and  to  whisper, 
while  tuning-fork  vibrations  were  better 
heard  through  the  bone.  Sixteen  cases 
remained  under  treatment  and  observa- 
tion from  six  to  eight  weeks.  Eight  re- 
mained subjectively  and  objectively  un- 
changed. Of  the  remaining  eight,  two 
showed  evident  improvement;  four  gave 
a  satisfactory  result;  while  in  two  there 
was   a  marked   and   continued  improve- 


ANIMAL  EXTRACTS.     THYROID.     MUSCULAR  ATROPHY.     ACROMEGALY. 


385 


ment  in  hearing.  Briihl  (Monat.  f. 
Ohren.,  Jan.,  '97). 

Eight  cases  of  sclerosis  of  the  middle 
ear  treated  with  thyroid  tablets,  about 
5  grains  given  daily  for  periods  varying 
from  thirty  to  eighty  days.  In  none  of 
the  cases  were  there  any  bad  results, 
either  in  the  ears  or  general  system.  A 
permanent  improvement  in  hearing  was 
obtained  in  three  of  the  eight  cases.  A. 
Eitelberg  (Archiv  f.  Ohren.,  vol.  xliii. 
Part  1,  '97). 

Trial  of  thyroidin  in  fourteen  cases  of 
deafness — due  in  eight  cases  to  adhesive 
processes,  in  six  to  sclerosis.  All  the 
cases  had  previously  undergone  other 
treatment  without  success.  Treatment 
terminated  at  the  end  of  three  weeks 
where  no  improvement  had  occurred. 
Nine  cases  showed  no  improvement.  Two 
had  some  diminution  of  tinnitus.  In  two 
a  marked  gain  in  hearing  was  experi- 
enced. Morpurgo  (Rev.  Hebd.  de  Lar., 
Apr.  23,  '98). 

Results  arrived  at  by  careful  treat- 
ment, after  the  manner  of  Briihl,  of  21 
cases  of  middle-ear  disease  with  thyroid. 
Duration  of  disease  varied  from  one  to 
twenty  years.  There  were  15  cases  of 
sclerosis,  3  of  middle-ear  catarrh  with 
ossicular  ankylosis,  and  3  of  ossicular 
ankylosis  following  suppurative  disease. 
Nearly  all  the  cases  had  already  been 
treated  in  other  ways.  In  no  single  case 
did  any  benefit  result  from  the  thyroid, 
although  several  cases  were  benefited  by 
being  treated  by  other  methods.  Mac- 
leod  Yearsley  (Jour,  of  Laryng.,  Rhin., 
and  Otol.,  Sept.,  '98). 

Muscular  and  Osseous  Dtsteo- 
PHIES.  — Muscular  Atrophy.  —  The  fact 
that  two  cases  of  mtiscular  atrophy  were 
greatly  improTed  and  reported  as  such 
by  so  reliahk  an  observer  as  Lepine 
would  indicate  that  a  portion,  at  least, 
of  these  cases  can  be  benefited. 

Thyroid  gland  employed  in  two  cases 
of  muscular  atrophy  and  successful  re- 
sults obtained.  In  one  case — a  man,  44 
years  of  age,  who  had  suffered  for  eight 
years — 2  ounces  daily  had  been  admin- 
istered for  about  two  months.  Improve- 
ment   had    taken    place    in    about    two 

1- 


weeks  after  the  beginning  of  the  treat- 
ment.   The  patient  felt  stronger  and  had 
been  able  to  walk  alone,  which  he  had 
not  been  able  to  do  for  some  time.     L6- 
pine   (Revue  Inter,  de  M6d.  et  de  Chir., 
Aug.  10,  '96). 
Acromegaly. — The  reports  of  cases  of 
this  disease  treated  with  thyroid  have 
been  insufficient  to  warrant  a  conclusion, 
but  it  would  seem  probable  that  con- 
ditions due  to  disorders  associated  with 
myxosdema  or  goitre  could  alone  be  ex- 
pected, the  osseous  hypertrophy  being 
beyond  the  remedial  process. 


Case  illustrating  the  association  of  acro- 
megaly and  goitre.     (G.  R.  Murray.) 

Case  of  acromegaly  treated  with  dried 
thyroid  extract  in  gradually  increasing 
doses  until  12  grains  a  day  were  taken, 
besides  galvanism  and  tonics.  Three 
months  later  she  was  feeling  very  much 
better,  her  memory  had  improved,  and 
she  spoke  and  moved  more  rapidly.  She 
had  lost  over  twenty  pounds  in  weight, 
but  felt  stronger.  General  condition 
practically  the  same.  The  history  of  the 
case  and  the  marked  physical  changes 
leave  little  doubt  that  it  was  a  case  of 
acromegaly,  but  certain  anomalous  symp- 
toms— such  as  the  puffy  conditions  of  the 
eyelids,  which  may,  however,  have  been 
simply  the  result  of  anaemia,  though  its 
appearance  was  somewhat  different:    the 


386 


ANIMAL  EXTRACTS.     THYROID.     OBESITY. 


slow  speech,  and  the  altered  mental  state 
— suggested  that  her  condition  was  also 
associated  with  a  loss  of  function  of  the 
thyroid  gland.  G.  G.  Sears  (Boston  Med. 
and  Surg.  Jour.,  July  2,  '96). 

Case  of  a  woman,  26  years  old,  who 
had  suffered  from  acromegaly  for  upward 
of  two  years,  and  who  for  a  period  of 
five  months  had  been  treated  with  mixed 
pituitary    and    thyroid    extracts,    with 
great  improvement.     The  superficial  re- 
semblance between  acromegaly  and  myx- 
ffidema  seemed  to  justify  the  administra- 
tion of  thyroid  extract,  especially  as,  in 
several    cases   of   acromegaly,   treatment 
with  pituitary  extract  alone  had  failed 
to   effect   any    improvement.      RoUeston 
(Brit.  Med.  Jour.,  Apr.  17,  97). 
Obesity.  • —  The   selective   action    on 
adipose  tissues  shown  to  attend  the  in- 
creased  metabolism   brought   about   by 
thyroid,  and  the  decided  increase  in  the 
nitrogen  excretion  sustain  the  use  of  this 
agent  in  obesity.    The  effects  have  been 
irregular,    hov?ever,    some    patients    re- 
sponding readily  to  the  influence  of  the 
remedy,  but  others  not  doing  so.     The 
views  of  the  French  authors  in  this  par- 
ticular  perhaps   afford   an   explanation, 
namely:    young,  vigorous,  and  plethoric 
individitals,  who  are  good  livers,  receive 
little  or  no  benefit  from  thyroid  treat- 
ment, but  are  benefited  by  a  dietetic 
regimen.     On  the  other  hand,  fat  per- 
sons that  are  pale,  soft,  and  flabby,  and 
inclined  .to  oedema,  receive  benefit  from 
the  ingestion  of  the  thyroid  gland.    They 
lose    weight    rapidly,    oxidation    is    in- 
creased, and  nutrition  is  improved.    We 
are  again  brought  face  to  face  with  con- 
ditions showing  some  of  the  elements  of 
myxoedema. 

Besides  the  dangers  attending  the  use 
of  thyroid  in  any  case,  the  only  source 
of  untoward  effects  is  the  giving  of  large 
doses  at  first,  the  organs,  especially  the 
heart,  being  thus  exposed  to  the  effects 
of  undue  reaction.  In  appropriate  eases 
the  remedy  is  taken  without  trouble,  and 


the  effects  soon  show  themselves.  After 
a  time  the  reduction  in  weight  is  propor- 
tionately smaller,  and  discontinuance  of 
the  treatment  is  followed  by  recurrence, 
in  the  great  majority  of  cases,  until  the 
former  weight  is  reached.  To  maintain 
the  advantage  gained,  however,  dieting 
and  small  doses  of  thyroid  at  longer  in- 
tervals may  be  utilized  with  advantage. 

Case  of  obesity  treated  by  thyroid 
juice,  15^/2  minims  daiV,  either  by  sub- 
cutaneous injection  or  by  the  mouth.  In 
three  months  weight  fell  from  292  to  253 
pounds.  As  soon  as  the  treatment  was 
discontinued  the  loss  of  flesh  also  ceased, 
and  when  the  thyroid  extract  was  re- 
sumed a  daily  loss  of  1  "/j  to  4  Vs  ounces 
was  observed,  this  becoming  less  after  a 
time.  A  second  case  treated  showed  sim- 
ilar, but  less  marked,  results,  while  in  a 
third  no  effect  could  be  noted.  The  in- 
constancy of  results  perhaps  depended 
upon  the  different  forms  of  obesity,  upon 
the  insufficiency  of  the  treatment,  or 
upon  the  extract  used,  which  may  not 
have  been  genuine.  Charrin  (La  Sem. 
M6d.,  Jan.  2,  '95). 

The  thyroid  gland  of  the  sheep  a  spe- 
cific in  obesity;  free  from  danger  and 
injurious  after-effects,  and  the  beneficial 
results  of  which  appear  within  a  few 
months  from  beginning  of  treatment. 
The  sole  risk  is  in  beginning  with  large 
doses,  as  palpitations  and  fainting  fits 
are  possible  until  the  patient  is  well  ac- 
customed to  the  drug.  Frederick  Gutt- 
mann  (Amer.  Medico-Surg.  Bull.,  May 
15,  '95). 

Case  of  a  man  who  took  a  large  quan- 
tity of  tablets  in  the  hope  of  reducing 
his  obesity  and  became  maniacal  within 
a  few  days;  oedema  of  the  brain  was 
found  at  the  necropsy.  Stabel  (Lancet, 
Mar.  28,  '96). 

In  excessive  obesity  with  tendency  to 
weakness  and  anaemia,  in  which  exercise 
and  diet  fail,  thyroid  extract  should  be 
tried.  H.  C.  Wood  (Univ.  Med.  Mag., 
Apr.,  '96). 

Of  considerable  value  to  reduce  weight 
in  obesity,  especially  in  the  ansemic, 
flabby  types,  and  provided  the  relapse  is 


ANIMAL  EXTRACTS.     THYROID.     SYPHILIS.     TETANY. 


387 


prevented  by  diet  and  exercise.  Cabot 
(Medical  News,  Sept.  12,  '96). 

Tabloids  of  the  whole  gland-substance 
,  disagree  in  some  instances,  owing,  no 
doubt,  to  the  fatty  matter  they  contain. 
Colloid  tablets  not  prepared  according 
to  the  method  advocated  by  Dr.  Hutch- 
inson decidedly  disappointing.  Of  the 
three  sorts  of  tabloids  used,  those  pre- 
pared according  to  Dr.  Hutchinson's 
process  the  most  efficacious.  P.  .Jervis 
(Brit.  Med.  Jour.,  Oct.  2,  '97). 

Unpleasant  and  even  serious  symptoms 
observed  after  the  administration  of  thy- 
roid extracts;  attributed  to  the  presence 
of  toxic  decomposition  products.  By  the 
employment  of  iodothyrin  —  an  active 
principle  of  the  gland — these  unfavorable 
symptoms  can  be  practically  obviated. 
Used  in  seventeen  cases  of  simple  obesity, 
it  brought  about  a  reduction  of  Aveight 
without  the  aid  of  other  treatment.  In 
five  cases  there  was  diminution  in  Aveight 
after  fifteen  days'  treatment.  Lutaud 
(Coll.  and  Clin.  Eec,  Dec,  '97). 

Three  cases  of  obesity  in  which  was 
used  a  new  preparation  of  thyroid  gland 
known  as  thyroglandin.  One  grain  was 
given  three  times  daily  for  a  few  days. 
Dose  was  then  rapidly  increased  until  9 
grains  Avere  taken  in  the  course  of  the 
day.  Decrease  in  Aveight  Avas  rapid  and 
persistent  in  all  cases  and  Avas  unaccom- 
panied by  the  unpleasant  symptoms  so 
commonly  experienced  Avith  other  prepa- 
rations used  for  this  purpose.  MacLen- 
nan  (Brit.  Med.  Jour.,  July  9,  '98). 

The  most  serious  disadvantage  lies  in 
the  lack  of  permanency  of  its  action. 
The  most  marked  results  are  to  be  ob- 
served in  the  first  Aveeks  of  the  treat- 
ment, Avhile  after  a  feAv  months  the 
system  may  become  so  accustomed  to 
the  remedy  that  the  patient  not  only 
ceases  to  lose  his  superfluous  avoir- 
dupois, but  may  actually  regain  much 
of  the  flesh  lost.  After  cessation  of 
the  treatment  there  is  quite  com- 
monly a  strong  tendency  of  the  body  to 
return  to  its  previous  condition.  If  we 
wish  our  treatment  of  obesity,  either  by 
the  thyroid  or  diet,  to  be  permanent,  Ave 
must  insist  on  a  continuance  of  abstemi- 
ous habits:  a  point  on  Avhich  the  origi- 
nator   of    the    thyroid    method,    Yorke- 


Davies,  lays  especial  stress.    H.  B.  Wood, 
Jr.  (Merck's  Archives,  July,  '99). 

Four  cases  of  juvenile  obesity  treated 
Avith  the  thyroid  extract.  One  a  boy, 
aged  8  years,  Aveighed  before  treatment 
131  pounds.  With  purgation,  diet,  and 
exercise  he  Avas  ordered  2 '/,  grains  of 
thyroid  extract  three  times  a  day,  Avith 
a  gradual  increase  until  a  5-grain  tablet 
Avas  taken  four  times  a  day.  After 
fourteen  months'  treatment  he  Aveighs 
106  pounds  and  he  has  developed  muscle 
to  a  considerable  degree.  I.  N.  Love 
(Jour.  Amer.  Med.  Assoc.,  Apr.  21,  1900). 

Syphilis.  —  Thyroid  extract  has  not 
been  extensively  tried  in  this  affection, 
but  the  few  cases  reported  would  seem  to 
indicate  that  it  assists  alteratives,  mer- 
curials, etc.,  by  stimulating  metabolism. 
In  a  few  cases  thyroid  extract  apparently 
modified  the  syphilitic  process  independ- 
ently of  the  usual  remedies  employed. 

Case  of  syphilitic  psoriasis.  After  five 
Aveeks'  treatment  by  mercury  and  ar- 
senic there  was  considerable  improve- 
ment, but  this  line  Avas  stopped  and  the 
patient  placed  on  thyroid.  In  three 
Aveeks  the  disease  had  disappeared,  leav- 
ing only  the  usual  pigmentation.  John 
Gordon  (Brit.  Med.  Jour.,  Jan.  27,  '94). 

Cases  of  malignant  syphilis  treated 
Avitli  thyroidin:  cachectics,  presenting 
squamous,  ulcerous,  osseous  lesions,  Avhich 
had  previously  been  treated  in  vain  Avith 
mercurials  and  iodides.  Thyroidin  (dry 
extract  of  thyroid  glands),  4  to  7  V4 
grains  daily,  in  tablets,  administered, 
suspending  specific  medication.  Cutane- 
ous and  osseous  lesions  healed  in  part; 
even  the  pigmented  spots  of  the  skin 
Avere  seen  to  disappear.  Menzies  (Brit. 
Med.  Jour.,  July  7,  '94). 

Case  of  severe  syphilis  cured  by  inges- 
tion of  thyroid  gland.  Thirty  grains 
progressively  increased  by  same  amount 
until  3  V2  drachms  taken  at  a  dose. 
Every  second  day  treatment  interrupted 
twenty-four  hours.  Guladze  (Wratsch, 
No.  30,  '95). 

Tetany.  —  The  fact  that  tetany,  as 
well  as  myxoedema,  has  not  rarely  been 
observed   after  extirpation   of  the   thy- 


388 


ANIMAL  EXTRACTS.     THYROID.     TORTICOLLIS.     UTERINE  DISORDERS. 


roid  gland  has  suggested  the  use  of  this 
remedy.  It  has  seemed  to  be  of  value, 
especially  in  the  idiopathic  tetany  of 
children. 

Form  following  total  removal  of  thy- 
roid gland  a  manifestation  of  acute  myx- 
oedema,  and  due  to  complete  arrest  of 
thyroid  secretion.  Thyroid  extract  cura- 
tive. Common  tetany  may  be  due  to 
lack  of  thyroid  secretion.  Thyroid  treat- 
ment should  be  tried.  Bramwell  (Brit. 
Med.  Jour.,  June  1,  '95). 

Case  which  presented  none  of  the 
symptoms  of  myxoedema  and  possessed 
an  apparently  healthy  thyroid  gland. 
Tablets,  1  to  3  daily,  consisting  of  4 
grains  of  thyroidin,  used  for  about  a 
month;  the  symptoms  entirely  disap- 
peared. Four  months  later  there  had 
been  no  recurrence;  hence  it  may  be  as- 
sumed that  the  cure  was  perfect.  Max 
Levy-Dorn  (Ther.  Monat.,  H.  2,  S.  63, 
'96). 

1.  In  the  idiopathic  tetany  of  children 
the  administration  of  the  thyroid  gland 
is  extremely  useful;  it  always  dimin- 
ishes the  intensity  and  the  frequency  of 
the  attacks,  and  shortens  the  duration 
of  the  disease;  it  also  notably  hastens 
the  arrival  of  the  latent  period  which 
precedes  recovery.  2.  The  treatment  is 
well  tolerated.  3.  The  organic  exchanges, 
the  digestive  function,  and  diuresis  are 
not  notably  influenced.  4.  The  circu- 
latory and  respiratory  functions  are  ac- 
complished normally.  5.  In  very  young 
children,  on  account  of  their  perfect 
tolerance,  it  is  useful  to  administer  the 
thyroid  gland,  raw  or  slightly  cooked, 
internally.  6.  With  the  exception  of  cer- 
tain peculiar  cases,  it  is  not  necessary 
to  suspend  the  treatment  from  time  to 
time.  7.  The  daily  dose  is  from  30  to 
60  gi-ains.  8.  This  treatment  is  not  op- 
posed to  the  symptomatic  treatment,  as 
it  does  not  present  any  incompatibility 
with  the  methods  ordinarily  employed. 
Leone  Maestro  (Riforma  Medica.  Xo. 
116,  '96). 

ToETicoLLis.  —  Spasmodic  torticollis 
would  also  seem  to  enter  within  the  field 
of  thvroid-gland  treatment,  although  a 


single  case  can  do  but  little  more  than 
suggest  its  further  trial. 

Case  of  spasmodic  torticollis  in  which 
thyroid  extract  was  used.  History  of 
four  attacks  of  influenza.  On  leaving 
his  bed  after  the  third  attack,  neuralgic 
pains  on  the  right  side  of  the  neck,  right 
shoulder,  upper  arm  and  side;  slight 
numbness  in  the  legs.  A  few  days  later 
violent  attack  of  pain,  during  which  his 
head  was  drawn  down  toward  the  right 
shoulder.  These  attacks  became  fre- 
quent, eventually  occurring  as  often  as 
three  or  four  times  in  an  hour.  The 
sterno-mastoid  was  slightly  hypertro- 
phied.  Ordered  10-mii.im  doses  of  thy- 
roid extract  to  be  taken  three  times  in 
the  day:  equal  to  about  one  average- 
sized  gland.  After  having  taken  2 
drachms  of  the  extract,  the  attacks  be- 
came less  frequent,  and  were  attended 
with  less  pain,  and  after  taking  about 
2  ounces  of  it  he  suffered  so  little  in- 
convenience that  he  discontinued  the 
treatment.  On  a  subsequent  occasion,  he 
was  kicked  by  a  horse  on  the  outer  right 
thigh;  great  tonic  muscular  spasm;  con- 
siderable shock.  For  two  days  the  spasm 
continued  unabated.  Thyroid  extract 
renewed;  after  taking  30  minims  the 
spasm  became  gradually  less,  and  on 
taking  the  drug  for  two  more  days  it 
completely  subsided.  H.  H.  P.  Cotton 
(Brit.  Med.  Jour.,  July  24,  '97). 

Uteeine  Disoedees. — Certain  condi- 
tions influencing  the  genital  apparatus 
— such  as  puberty,  pregnancy,  fibroid 
tumor,  which  cause  a  distinct  change  in 
the  metabolism  of  the  entire  organism — 
very  frequently  cause  an  enlargement  of 
the  thyroid  gland.  Again,  the  deficiency 
of  the  normal  thyroid  secretion  follow- 
ing thyroidectomy  in  myxoedema,  cre- 
tinism, etc.,  is  often  associated  with 
atrophic  changes  in  the  genital  appa- 
ratus, as  shown  by  Fisher,  of  Vienna. 
This  suiSciently  indicates  direct  associa- 
tion between  the  thyroid  and  the  genital 
system  to  warrant  careful  investigation 
into  the  uses  to  which  thyroid  extract 


ANIMAL  EXTRACTS.     THYHOID.     UTERINE  DISORDERS. 


389 


might  be  put  in  the  treatment  of  diseases 
of  the  reproductiYe  tract. 

The  deficiency  of  glandular  substances 
in  the  economy  experienced  at  the  meno- 
pause seems  to  suggest  that  there  is 
some  lost  principle  which  we  may  thera- 
peutically supply  until  the  system  has 
gradually  become  accustomed  to  effect 
the  necessaiy  metabolism  independently. 
Quite  recently  it  has  been  claimed  that 
iodine  salts  are  always  present  in  thyroid 
extract,  ■\\hieh  may  partly  explain  the 
efi'ect.  Leith  Napier  (Brit.  Gynaec.  Jour., 
Aug.,  '96). 

The  administration  of  thyroid  extract 
as  a  palliative  of  uterine  fibroids  caused 
improvement,  especially  in  cases  that 
took  the  remedy  longest.  The  mani- 
festations were:  (a)  control  of  the 
menstrual  flow;  (b)  arrest  of  the 
growth,  and,  in  some  cases,  diminution 
in  the  size  and  apparently  softening  of 
the  tumor;  (r)  disappearance  of  pain 
and  diminution  of  tenderness  in  the 
growth,  and  also  of  the  sense  of  abdom- 
inal and  pelvic  distension,  with  increase 
in  muscular  and  nervous  energy;  (d) 
betterment  of  the  general  nutrition, 
manifested  at  first  by  slight  loss  and 
then  by  return  of  flesh;  improved  state 
of  the  skin,  hair,  and  nails,  and  in  the 
substitution  of  a  good  color  for  the  ap- 
pearance of  anaemia.  The  nearer  the 
growth  approaches  the  type  of  pure 
myoma  as  distinct  from  fibromyoma,  the 
better  the  ultimate  result.  William  M. 
Polk  (Med.  News,  Jan.  14,  '99). 

1.  The  thyroid  gland,  in  addition  to  its 
general  effect  upon  the  metabolism  of 
the  body,  exerts  an  inhibitory  action 
upon  the  pelvic  genital  organs,  and 
upon  the  uterus  in  particular.  This  ac- 
tion seems  to  be  especially  marked  upon 
the  epithelial  elements  of  the  endo- 
metrium. 2.  As  a  result  of  this  inhibi- 
tory, or  vasoconstrictor,  action  there  fol- 
lows a  retardation  of  hsemorrhages  from 
the  uterine  mucosa.  3.  This  action  is 
directly  antagonistic  to  that  exerted 
upon  the  uterus  by  the  ovarian  secretion. 
4.  In  cases  in  which  this  conservative 
influence  is  deficient  or  absent  it  may  be 
restored  by  the  ingestion  of  fresh  thyroid 
gland  or  desiccations  or  extracts  of  that 


organ.    5.  In  gynaecology  thyroid  therapy 
is   especially   indicated    in    haemorrhagic 
affections  of  the  uterus  and  in  all  forms 
of  pelvic  congestion,  notably  in  uterine 
fibromata,      haemorrhagic      endometritis, 
menopausal    haemorrhages,    and    chronic 
tubal  diseases.     6.  The  best  results  are 
to  be  expected  in  fibromata  and  patho- 
logical conditions  of  recent  development. 
The  more  chronic  the  case,  the  more  re- 
bellious will  it  prove  to  thyroidization. 
7.  The  thyroid  influence  is  also  found  to 
cause  an  increase  in  the  metabolism  of 
the  mammary  gland,  and  the  treatment 
is  therefore  indicated  in  all  cases  of  in- 
sufficient   lactation.      W.    A.    Newman 
(Ther.  Gaz.,  July  15,  '99). 
So  far,  thyroid  extract  has  furnished 
marked  eyidence  of  its  value  for  the  pur- 
pose of  arresting  haemorrhage  whether 
this  occur  in  connection  with  abortion, 
the  menopause,  tumors,  or  uterine  mal- 
positions.   A  remarkable  case  of  metror- 
rhagia due  to  hfemophilia  successfully 
treated  with  thyroid  extract  is  reported 
by  Dejace. 

Thyroid  extract  an  excellent  remedy 
in  threatened  abortion  with  haemorrhage, 
and  is  valuable  in  preventing  the  arrest 
of  uterine  involution  after  childbirth. 
Ch6i-on  (Revue  iledico-Chir.  des  Mai.  des 
Femmes,  Nov.  25,  Dec.  25,  '96) . 

Thyroid  extract  is  particularly  favor- 
able in  cases  of  uterine  haemorrhage.  In 
purely  functional  cases  the  results  had 
been  a  complete  and  lasting  cure,  also 
in  the  hsemorrhages  of  menopause  or  de- 
pendent on  uterine  malpositions.  The 
growth  of  fibrous  tumors  is  also  checked 
by  retrogression,  and  cure  has  followed 
its  use  early  in  the  history  of  the  eases. 
Jouin  (Gyngcologie.  Oct.,  '97). 

Case  of  hfemophilia  treated  by  the 
thyroid  substance.  Face  and  mucous 
membrane  absolutely  colorless;  the  gums 
bled  profusely  at  the  least  touch.  The 
legs,  arms,  and  the  body  were  covered 
with  spots  of  purpura.  During  each 
menstrual  period  the  blood  was  dis- 
charged in  an  alarming  abundance,  and 
the  menses  lasted,  on  an  average,  from 
twelve  to  fourteen  days.  She  had  used 
all  the  haemostatics  without  avail.    Thy- 


390 


ANIMAL  EXTRACTS.     THYROID.     CANCER. 


roid  substance,  three  capsules  a  day.  was 
begun  ou  the  9th  of  October.  On  the 
I2th  the  menses  appeared,  and  instead 
of  continuing  for  twelve  days,  as  before, 
lasted  but  four  days  and  were  moderate 
in  quantity.  On  the  18th  the  loss  of 
blood  from  the  gums  disappeared.  Till 
the  27th  the  patient  had  had  no  haemor- 
rhage since  the  last  menstrual  period. 
The  purpuric  spots  had  disappeared  and 
the  gums  and  face  had  regained  a  rosy 
color.  The  thyroid  substance  exercises 
an  action  as  yet  unknown  on  the  plas- 
ticity of  the  blood.  M.  L.  Dejace  (In- 
dependance  Med.,  Nov.  24,  '97). 

Case  in  which  hasmophilic  epistaxis 
was  absolutely  unaffected  by  ordinary 
therapeutic  agents,  and  the  epistaxis 
became  so  persistent  and  exhausting 
that  permanent  blocking  of  the  nasal 
fossa  was  necessary.  Treatment  by  thy- 
roid extract  exerted  an  immediate  and 
benefieial  effect,  and  was  followed  by 
cure.  In  three  days  the  violent  and  per- 
sistent epistaxis  had  practically  stopped. 
In  six  days,  about  8  gi'ains  of  thyroid 
extract  having  been  given  daily,  the 
purpuric  eruption  ceased  and  the  old 
spots  began  to  disappear.  Scheffler 
(Archives  de  iled.  et  de  Pliarm.  Mil, 
March,   1901). 

Cancee. — Thyroid  has  recently  been 
tried  in  tliis  afifection,  hut  the  cases  re- 
ported have  been  too  few  to  warrant  any 
conclusion  as  to  its  merits.  Thus,  D. 
McMcol,  of  Glasgow  (Brit.  Med.  Jour., 
ISTov.  9,  1901),  after  referring  to  an 
analysis  of  forty-nine  eases  thus  treated, 
tried  thyroid  extract  in  four  personal 
cases,  and  reached  the  conclusion  that  it 
did  not  even  prolong  life.  In  our  opin- 
ion, the  concomitant  use  of  hypoder- 
moclysis  would  have  insured  a  better  re- 
sult. 

Case  of  a  woman  who  had  a  mammary 
tumor  which  was  at  first  thought  to 
be  malignant.  Thyroidin  was  given, 
and  there  was  a  rapid  decrease  in  the 
size  of  the  tumor,  and  it  idtimately 
praeticallj'  disappeared.  Similar  effects 
were  observed  in  two  cases  in  which 
there  were  large  lyniphomata  and  also 


in  three  cases  of  marked  splenic  en- 
largement without  increase  of  leuco- 
cytes. Arthur  Jaenieke  (Centralb.  f. 
innere  Med.,  Jan.  12,  1901). 

Case  of  widespread  carcinoma  in  a 
woman,  aged  44  years,  in  whom  thyroid 
extract,  in  5-grain  doses  varying  from 
two  to  four  times  daily,  given  for  six 
months,  produced  great  amelioration  of 
the  symptoms.  The  symptoms  returned, 
however,  in  spite  of  persistence  of  the 
treatment.  P.  B.  Smith  (Brit.  Med. 
Jour.,  Feb.  16,  1901). 

Case  of  uterine  cancer  in  which  the 
improvement  followed  so  quickly  upon 
the  emploj'ment  of  the  remedy,  and  was 
so  striking,  that  in  his  own  mind  the 
author  has  not  the  slightest  doubt  that 
it  was  entirely  due  to  its  use,  and  he 
is  certain  that  thyroid  extract  should 
always  be  given  a  trial  in  this  class  of 
cases  before  more  heroic  measures  are 
adopted.  H.  A.  Beaver  (Brit.  Med. 
Jour.,  Feb.  1,  1902). 

The  removal  of  the  ovaries,  provided 
they  are  actively  functionating,  fre- 
quently causes  an  arrest  of  the  malig- 
nant mammary  growths,  and  sometimes 
their  complete  cure.  This  action  is 
materially  aided  by  excision  of  as  much 
as  possible  of  the  neoplasm,  supple- 
mented by  the  administration  of  thyroid 
extract  in  full  doses.  In  women  past  the 
menopause,  the  excision  of  these  organs 
is  not  so  effective,  while  in  others  relief 
appears  within  twenty-four  to  forty-eight 
hours,  and  in  favorable  cases  is  rapidly 
progressive.  The  dose  of  thj'roid  extract 
that  can  be  safely  employed  varies  from 
10  to  15  grains  daily.  Though  this 
method  should  not  result  in  perfect  cure, 
it  is  the  best  palliative  operative  pro- 
cedure yet  devised.    (Borland.) 

Two  cases  in  which  oophorectomj'  plus 
the  administration  of  thyroid  gland  had 
given  successful  results.  In  one  case  the 
treatment  brought  about  the  healing  of 
a  large  carcinomatous  ulcer  of  the  right 
breast  which  had  recurred  after  two 
operations  for  removal  by  surgical  means, 
and  had  determined  the  disappearance  of 


ANIMAL  EXTRACTS.     THYMUS.     GOITRE. 


391 


a  large  tumor  in  the  other  breast,  the 
nature  of  which  was  shown  by  the  en- 
largement of  the  corresponding  axillary 
glands,  which  glands  also  had  ceased  to 
be  perceptible  to  the  touch.  G.  Herman 
(Med.  Press  and  Circ,  Apr.  22,  '99). 

Dr.  Herman's  first  case  remains  well 
twenty-five  months  after  the  operation 
and  his  second  nine  months  after.  Six 
other  cases  (treated  by  Dr.  Beatson,  Dr. 
Cheyne,  and  self)  were  disappointing 
failures.  Perhaps  thyroid  was  not  stead- 
ily persisted  in  throughout  all  these 
cases,  but  it  Avas  given  at  first  and 
would  doubtless  have  been  continued  had 
it  seemed  to  do  good.  Such  facts  as  we 
have  before  us  support  (not  establish) 
the  view  that  oophorectomy  is  by  far  the 
most  important  factor  in  the  treatment, 
and  that  it  may  be  the  only  one.  Stan- 
ley Body  (Lancet,  Apr.  29,  '99). 

Thymus  Gland. 

This  organ  having  been  accidentally 
substituted    for    thyroid    in    a    case    of 
Owen's    and   benefit    procured,    it    was 
found  to  produce  analogous  effects  in 
other  cases.     This  led  Svehla  to  under- 
take a  series  of  experiments  to  determine 
its  physiological  action.     Injected  into 
the  femoral  vein,  thymus  extract  gave 
rise  to  a  fall  of  blood-pressure,  due  to 
weakening  or  paralysis  of  the  vasocon- 
strictors, and  increase  of  pulse-rate,  due 
to  direct  influence  on  the  heart.    Wlien 
large  doses  were  given  there  was  excite- 
ment, followed  by  dyspnoea  and  collapse, 
ending  in  death,  with  post-mortem  evi- 
dences of  asphyxia.     A  certain  analogy 
was  thus  shown  to  exist  with  the  physi- 
ological action  of  thyroid,  and  this  was 
further  emphasized  by  the  observations 
of  Baumann,  who  found  that  the  thymus 
contained   iodine,   as    does   thyroid,    al- 
though in  comparatively  small  quantities. 
In  the  urine  of  dogs  fed  with  thymus 
gland   has   been    found   a   peculiar   sub- 
stance   that    has    the    formula    approxi- 
mately of  CsNjHjOj  and  which  is  believed 
possibly  to  be  an  imidopseudouric  acid: 
that  is,  an   oxidation-product  of   imido- 


hypoxanthin.     It  is  also  possible  that  It 
is    allantoin,    and    this    seems    to   agree 
with  some  of  its  chemical  reactions.     It 
is  important  as  perhaps  contributing  to 
the  explanation  of  the  form  of  uric  acid 
derived  from  nucleinic  acid.     Minkowski 
(Centralb.  f.  innere  Med.,  May  14,  '98). 
Dose. — The  doses  of  thymus  adminis- 
tered have  been  much  larger  than  would 
be  prudent  in  the  case  of  thyroid.     Of 
the  gland  proper  the  doses  have  ranged 
from  2  ^/j  drachms  to  1  ounce,  given 
three  to  five  times  a  week;    while  the 
extract  has  been  given  in  doses  ranging 
from  30  to  60  grains. 

Therapeutics. — Young  sheep's  glands 
should  invariably  be  used;  the  glands 
of  older  sheep,  having  undergone  fatty 
transformation,  are,  therefore,  worthless. 
GoiTEE. — In  this  disease  thymus  seems 
to  produce  the  same  effects  as  thyroid 
gland,  when  administered  in  suf&ciently 
large  doses.  In  fact,  from  the  results 
obtained  it  would  appear  that  the  thymus 
is  but  a  thyroid  six  times  weaker  in  cura- 
tive activity. 

Three  cases  in  which  diet  of  thymus 
produced  good  results:  12  to  15  (3 
grains)  tabloids  given  daily.  Cunning- 
ham (N.  Y.  Med.  Record,  June  15,  '95). 
In  the  majority  of  the  cases  observed, 
a  reduction  in  the  size  of  the  goitre  and 
an  amelioration  or  removal  of  unpleasant 
symptoms  has  taken  place.  Thymus  is 
to  be  preferred  to  thyroid  feeding.  G. 
Reinbach  (Mittheilungen  aus  den  Grenz- 
gebeiten  der  Med.  u.  Chir.,  B.  1,  H.  2). 
Ten  cases  of  goitre  treated  with  thy- 
mus gland,  the  ages  ranging  between  13 
and  28  years.  From  2  Va  drachms  to  ^7, 
ounce  of  raw  sheep-thymus  were  given 
on  bread  three  times  a  week  and  in- 
creased to  7  drachms.  In  one  case  of 
small  goitre  complete  recovery  was  ef- 
fected within  two  weeks.  In  six  cases 
there  was  a  marked  reduction.  In  two 
cases  there  was  slight  improvement;  one 
was  not  benefited.  Mikulicz  (Berliner 
klin.  Woch.,  Apr.  22,  '95). 

Thirty   cases    of   goitre    treated    with 
thvmus  extract.     In  twentv  decided  re- 


392 


ANIMAL  EXTEACTS.     THYMUS.     EXOPHTHALMIC  GOITRE. 


duetion  followed,  and  the  general  symp- 
toms were  improved.  Among  these  were 
a  number  of  cases  but  slightly  improved 
or  aggravated  by  thyroid  treatment.  A 
complete  cure  was  obtained  in  but  two 
cases.  Mikulicz  (Centralb.  f.  Chir.,  p. 
929,  '96). 

Exophthalmic  Goitee.  —  In  exoph- 
thalmic goitre  improvement  is  reported 
to  have  been  obtained  in  about  one- 
half  of  the  cases  treated,  but  there  is  a 
striking  lack  of  concordance  between  the 
various  reports,  some  authors  reporting 
series  of  cases  in  which  all  cases  were 
materially  benefited,  others  reporting 
failures  on  all  sides.  In  a  recent  paper 
Hector  Mackenzie  described  a  series  of 
experiments  having  for  their  object  to 
determine  the  actual  status  of  the  ques- 
tion. He  compared  results  obtained  in 
15  cases  in  which  thymus  was  used  by 
other  phj'sicians  to  20  cases  tinder  his 
own  charge.  In  the  15  cases  from  other 
sources  there  was  marked  general  im- 
provement in  no  less  than  14;  in  7  the 
pulse-rate  was  markedly  diminished;   in 

3  there  was  complete  and  in  4  partial 
disappearance  of  exophthalmos.  Of  the 
20  personal  cases,  1  died;  in  6  there 
was  no  improvement;  in  13  slight  im- 
provement. As  to  the  pulse-rate,  in  12 
there  was  no  change;  in  2  it  was  in- 
creased; in  5  it  was  slightly  and  in  1 
markedly  diminished;  but  in  this  1  the 
improvement  was  merely  transitory.  Of 
20  other  cases  in  which  remedies  other 
than  thymus  were  employed,  in  11  there 
was  no  change,  in  2  slight  increase,  in 

4  markedly  and  in  3  slightly  dimin- 
ished pulse-rate;  so  that,  from  the  side 
of  the  heart,  there  was  no  special  bene- 
fit from  the  thymus.  As  to  the  goitre, 
in  3  cases  there  was  material  diminution 
in  size,  and  in  3  enlargement  from  thy- 
mus. Of  the  20  contrast  cases:  in  13 
there  was  no  change,  in  4  cases  more  or 
less   diminution,   in    1    complete   disap- 


pearance, and  in  1  enlargement.  The 
balance,  therefore,  is  against  the  thymus 
treatment.  As  to  the  exophthalmos, 
diminution  occurred  in  only  1  case,  and 
this  commenced  before  thymus  was  tried. 
In  the  20  contrast  cases,  3  lost  the  ex- 
ophthalmos. In  the  matter  of  general 
nutrition  there  was  a  slight  weight  in 
favor  of  the  cases  under  treatment  by 
thymus.  Williams  reported  a  case  in 
which  the  symptoms  were  perceptibly 
aggravated  and  Kinnicutt,  in  two  test- 
cases  carefully  watched,  could  observe 
no  improvement. 

Case  treated  by  raw  sheep's  thymus  in 
doses  of  2  V2  drachms  to  7  drachms  in 
gradually  increasing  doses  about  three 
times  weekly.  The  subjective  symptoms 
— the  exophthalmos  and  tachycardia — 
were  all  diminished,  but  the  goitre  and 
tremor  remained  unchanged.  Mikulicz 
(Berliner  klin.  Woch.,  Apr.  22,  '95). 

Case  treated  with  capsules  of  dried 
thyroid,  continued  nearly  two  months 
without  any  perceptible  influence  upon 
her  condition  or  upon  the  secretions,  urea 
and  uric  acid  being  quantitively  exam- 
ined. After  trying  potassium  bromide, 
nuclein,  and  an  extract  of  spleen  without 
favorable  result,  the  patient,  on  July 
15th,  began  to  take  capsules  of  dried 
aqueo-glycerin  extract  of  the  thymus 
gland,  3  a  day,  each  of  which  contained 
1  V:  grains.  On  August  5th  feeling 
much  better,  although  there  were  no 
obvious  changes  in  the  symptoms;  on 
September  7th  she  was  discharged  re- 
lieved. After  having  stopped  the  use  of 
the  thymus,  in  about  four  weeks  after 
leaving  the  hospital,  she  was  again  pro- 
vided with  capsules  to  take  twice  a  day 
On  December  6th  the  pulse  was  92.  Im- 
provement; swelling  of  the  thyroid  less, 
and  patient  able  to  work.  R.  T.  Edes 
(Boston  Med.  and  Surg.  Jour.,  Jan.  23, 
'96). 

Case  of  exophthalmic  goitre  which,  in 
spite  of  all  treatment,  became  steadily 
worse.  Thymus-gland  medication  was 
begun  and  continued  with  the  best  re- 
sults. The  patient  felt  so  well  that,  the 
supply    of   tabloids    being   finished,    she 


ANIMAL  EXTRACTS.     THYMUS.     EXOPHTHALMIC  GOITRE. 


393 


stopped  the  treatment,  and  in  a  few 
weeks  the  exophthalmos  was  back  again 
to  a  considerable  extent.  The  tabloids 
were  resumed,  and  in  a  short  time  their 
benefit  was  noticeable.  N.  J.  McKie 
(Brit.  Med.  Jour.,  Mar.  14,  '96). 

Four  cases  treated  by  thymus.  It  cer- 
tainly does  improve  the  deranged  heart- 
action,  but  it  seems  more  pai-ticularly  to 
lessen  the  gastro-intestinal  symptoms 
and  the  tremor  and  general  muscular 
weakness.  Three  of  the  cases  had  pre- 
sented great  psychical  alteration;  in  all 
of  them  the  mental  state  has  improved 
readily.  A.  Maude  (Lancet,  July  18, 
'96). 

Case  of  exophthalmic  goitre  in  a  girl 
of  22.  Pulse,  156  and  very  irregular, 
both  in  force  and  frequency.  Thirty 
grains  of  dried  thymus  in  the  form  of 
tabloids  given  daily,  and  on  the  third 
day  the  pulse  had  fallen  to  130  and  Avas 
quite  regular.  The  amount  of  thymus 
was  gradually  increased  to  100  grains 
daily;  at  the  end  of  three  weeks  the 
pulse  had  fallen  to  73  and  was  regular. 
The  size  of  the  thyroid  was  not  dimin- 
ished, but  the  exophthalmos  was  less 
marked.  C.  Todd  (Brit.  Med.  Jour.,  July 
25,  '96). 

Three  eases  of  exophthalmic  goitre 
treated  with  thymus  gland.  All  three 
were  restored  to  health  by  the  treat- 
ment. The  dose  of  the  raw  gland  was 
from  half  an  ounce  to  an  ounce  three 
or  four  times  a  week.  In  one  of  the 
cases  discontinuance  of  the  gland  was 
followed  by  relapse,  but  on  resuming  it 
the  patient  again  improved.  Upon  one 
occasion  a  patient  who  always  had  been 
benefited  by  the  treatment  failed  to  re- 
spond to  the  glands.  This  was  found  to 
be  due  to  their  having  been  taken  from 
full-grown  sheep.  On  giving  calves'  thy- 
mus most  urgent  symptoms  were  at  once 
relieved,  especially  dyspncea,  palpitation, 
and  tremors.  David  Owen  (Lancet,  Aug. 
22,  '96). 

Case  of  twenty  years'  duration  in 
which  ordinary  remedies  were  tried  with- 
out benefit.  Raw  thymus  obtained  from 
the  lamb,  in  doses  of  2  drachms  daily 
for  three  months,  caused  the  cardinal 
symptoms  to  disappear.  The  treatment 
was    discontinued    after    seven    months. 


Three  months  later  there  was  a  return  of 
goitre,  tachycardia,  and  slight  exophthal- 
mos. He  resumed  the  thymus,  taking  'A 
ounce  or  more  cf  the  raw  gland  three 
or  four  times  a  week.  After  three 
months  the  exophthalmos  and  goitre  had 
quite  disappeared,  the  pulse,  instead  of 
120  and  over,  was  72.  The  following 
autumn  the  patient  was  unable  to  take 
the  gland  any  longer,  on  account  of  its 
nauseating  effects.  At  the  end  of  three 
months  the  old  disease  was  returning. 
He  again  resorted  to  the  thymus,  but 
took  it  for  two  months  without  any 
eS'ect  whatever.  Lambing  season  cor- 
responding to  the  spring,  however,  the 
failure  of  the  glands  doubtless  due  to 
the  fact  that  the  glands  had  been  taken 
from  older  sheep  than  before.  Calf's  thy- 
mus tried,  lamb's  not  being  obtainable. 
For  some  time  the  patient  was  worse; 
but,  during  severe  suffering  he  took 
about  "A  ounce  of  calf  s  thymus,  and  re- 
peated the  dose  in  the  morning.  During 
the  following  week  he  improved  remark- 
ably. The  improvement  continued  dur- 
ing the  winter,  but  there  was  a  return 
of  symptoms  this  summer.  Now  suffers 
from  occasional  palpitation,  sense  of 
weakness,  and  low  spirits,  and  some 
prominence  of  the  eyes.  David  Owen 
(Brit.  Med.  Jour.,  Oct.  10,  '96). 

Case  of  a  girl,  21  years  of  age,  who 
had  applied  for  treatment  for  palpitation 
of  the  heart,  prominence  of  the  eyes,  and 
swelling  in  the  neck,  first  been  observed 
two  years  ago.  All  three  symptoms  were 
less  striking  than  before  the  use  of  thy- 
mus gland,  begun  two  months  before  re- 
port. C.  E.  Nammack  (Med.  Record, 
Apr.  17,  '97). 

Improvement  in  six  out  of  twelve  cases 
of  exophthalmic  goitre.  The  goitre,  ex- 
ophthalmos, and  palpitation  were  im- 
proved, and  nervousness,  insomnia,  and 
tremor  very  much  relieved.  Solomon 
Solis-Cohen  (Amer.  Jour.  Med.  Sciences, 
p.  132,  '97). 

The  best  results  in  the  treatment  of 
exophthalmic  goitre  can  be  obtained 
from  the  joint  administration  of  thymus 
and  suprarenal  substances.  Solomon 
Solis-Cohen  (Phila.  Polyclinic,  Sept.  7, 
'98). 

Marked  case  of  Graves's  disease,  rebell- 


394 


ANIMAL  EXTRACTS.  SUPRARENAL  EXTRACT. 


ious  to  other  treatment  for  three  years 
and  threatening  melancholia,  improved 
in  a  week  and  practically  cured  in  three 
months,  with  15  to  25  grains  of  extract 
of  lamb-thymus  a  day.  The  only  symp- 
tom left  was  a  slight  enlargement  of  the 
thyroid.  C.  E.  Boisvert  (Revue  Med.  de 
Montreal,  June  21,  '99). 

Four  cases  of  exophthalmic  goitre 
treated  with  thymus  extract.  In  two  no 
perceptible  effect  was  obtained.  In  the 
two  others  there  was  considerable  im- 
provement amounting  practically  to  a 
cure  in  one  case.  W.  R.  Parker  (Brit. 
Med.  Jour.,  Jan.  7,  '99). 

From  the  cases  narrated,  there  is  reason 
to  believe  that  furtlier  use  of  thymus  or 
its  preparations  will  demonstrate  that  it 
is  superior  to  thyroid  in  exophthalmic 
goitre,  although  it  may  not  prove  more 
ef&eaeious  than  the  remedies  usually  em- 
ployed in  the  treatment  of  this  disease. 

Suprarenal  Extract. 

To  try  to  establish  the  therapeutic 
application  of  suprarenal  gland  or  its 
preparations  upon  a  solid  foimdation  for 
the  present  would  be  a  futile  effort, 
physiologists  having  not,  as  yet,  ivlly 
determined  any  of  the  purposes  of  the 
organs  themselves  in  the  human  econ- 
omy. Quoting  Horatio  C.  Wood  (1896), 
"The  functions  of  the  suprarenal  cap- 
sules still  remain  a  mystery.  This  only 
is  certain:  that  disease  of  these  cap- 
sules is  followed  by  a  progressive  asthe- 
nia, a  peculiar  bronzing  of  the  skin,  and 
loss  of  digestive  power  with  excessive 
vomiting,"  while  Stockman,  referring  to 
its  secretion,  wonders  whether  its  absence 
leads  to  a  toxic  condition  of  the  blood 
which  poisons  the  other  tissues,  or 
whether  the  want  of  it  leads  directly  to 
an  atonic  state  of  the  whole  muscular 
system.  These,  he  thinks,  are  questions 
which,  for  the  present,  must  be  left  open, 
along  with  many  other  important  points, 
such  as  the  origin  of  the  pigment,  etc., 
which  are  still  very  obscure. 


As  previously  stated,  this  work  is  in- 
tended to  portray  the  prevailing  viev/s  of 
the  profession,  and  not  our  own  doc- 
trines, pending  confirmation  of  the  lat- 
ter. The  interpretation  of  Auld  (Brit. 
Med.  Jour.,  June  3,  1899)  presents,  in 
the  aggregate,  the  conclusions  to^  which 
other  investigators  have  been  led: — 

"The  available  evidence  goes  to  show 
that  the  suprarenal  acts  by  destroying 
deleterious  substances,  and  also  by  ftir- 
nishing  a  material  to  the  blood.  As  the 
work  seems  to  be  done  by  the  medulla, 
there  is  considerable  ground  for  regard- 
ing the  vasoconstricting  substance  as  evi- 
dence of  the  former  function." 

Physiological  Action. — There  is  good 
ground  for  the  belief,  however,  especially 
since  the  experimental  investigations  of 
Brown-Sequard,  Abelous,  Langlois,  and 
Dubois,  that  the  physiological  function 
of  the  suprarenal  capsules  is  to  transform 
or  to  destroy  the  toxic  substances  which 
are  produced  in  the  organism  under  the 
influence  of  muscular  activity  and  of  the 
nervous  system.  The  destruction  of 
these  organs  is  thought  to  be  capable  of 
causing  in  the  organism  an  accumulation 
of  toxic  agents  which  is  the  principal 
cause  of  the  sensation  of  extreme  fatigue 
and  of  the  profound  and  generalized 
asthenia  experienced  by  patients  who 
suffer  from  Addison's  disease. 

The  evidence  that  the  suprarenal  cap- 
sules contain  a  toxic  substance  of  great 
activity,  much  more  active  than  that 
of  any  other  gland,  seems  quite  con- 
clusive. 

Extracts  made  from  the  suprarenal 
glands  of  the  calf,  sheep,  guinea-pig,  cat, 
dog,  and  man  have  a  similar  action.  Dis- 
eased glands  from  cases  of  Addison's 
disease  were  found  by  them  to  be  inert. 
The  active  principle,  whatever  it  is, 
must  therefore  be  recognized  as  an  ex- 
ceedinglj'   powerful    body,    if   we    reflect 


ANIMAL  EXTRACTS.  SUPRARENAL  EXTRACT. 


395 


that  of  this  Vi  grain  about  80  per  cent, 
io  water^  and  another  very  large  pro- 
portion must  consist  of  the  proteids,  etc., 
of  tlie  gland-substance.  Oliver  and 
Schilfer  (Jour.  Physiol.,  vol.  xviii,  pp. 
230-276). 

The  experiments  of  Dubois  would  tend 
to  show  tliat  the  toxic  substance  isolated 
is  identical  to  muscle-toxin:  e.g.,  orig- 
inating in  the  muscles.  Being  foreign 
to  the  capsules  themselves,  these  organs 
would  have  the  destruction  of  the  toxic 
products  as  their  physiological  function. 
Several  albumoses  found  in  the  capsules 
which  in  themselves  seem  to  possess  no 
well-marked  toxic  properties  would,  ac- 
cording to  Dubois,  possess  the  properties 
presented  by  the  organ  when  used  as  a 
remedy. 

Suprarenal  extract  is  much  more  toxic 
than  the  extracts  of  other  glands.  In- 
travenous injections  of  30  centigrammes 
to  1  gramme  of  a  25-per-cent.  solution 
in  glycerin  and  water  killed  a  rabbit  of 
1500  grammes  in  a  few  moments,  while 
6  to  12  grammes  of  other  extracts  did 
not  produce  death.  The  injection  was 
followed  at  once  by  paraplegia,  later  by 
convulsions  and  opisthotonos.  If  only 
injected  under  the  skin  the  animals  sur- 
vived several  daj's,  while  after  death 
nothing  but  parenchymatous  nephritis 
could  be  found.  Immediately  after  each 
injection  a  very  marked  increase  in  the 
blood-pressure  was  observed.  Gluzinsky 
(Wiener  klin.  Woch.,  '95). 

Toxic  substance  separated  from  the 
gland,  soluble  in  alcohol,  which  caused 
death  in  rabbits  from  respiratory  failure. 
It  had  no  paralytic  action,  but  seemed 
to  act  on  the  central  nervous  system. 
Gourfein  (Bull,  de  I'Acad.  de  Med.,  p. 
331,  '95). 

If  suprarenal  bodies  of  the  calf,  sheep, 
or  dog  were  injected,  even  in  very  small 
quantities,  into  a  vein  in  a  dog  or  a 
rabbit  the  following  pronounced  physi- 
ological effects  were  produced:  1.  Ex- 
treme contraction  of  the  arteries,  which 
was  shown  to  be  of  peripheral  origin.  2. 
A  remarkable  and  rapid  rise  of  the  arte- 
rial blood-pressure,  which  took  place  in 


spite  of  powerful  cardiac  inhibition,  and 
became  further  augmented  when  the  vagi 
were  cut.  3.  Central  vagus  stimulation 
so  pronounced  that  the  auricles  came  to 
a  complete  stand-still  for  a  time,  al- 
though the  ventricles  continued  to  con- 
tract, but  with  a  slow,  independent 
rhythm.  4.  Great  acceleration  and  aug- 
mentation of  the  contraction  of  the 
auricles  and  ventricles  after  section  of 
the  vagi, — the  auricular  augmentation 
being  especially  marked.  5.  Respiration 
only  slightly  affected,  becoming  shal- 
lower. G.  Oliver  and  E.  A.  Schafer  (Jour, 
of  Physiology,  Apr.,  '95). 

The  active  principles  of  adrenal  divided 
into  two  classes:  (1)  several  albumoses 
which  are  precipitated  Avith  alcohol  and 
redissolved  in  water  and  which  when 
isolated  have  no  well-marked  toxic  effect, 
but  which  alone  possess  the  property  of 
destroying  toxins,  especially  those  origi- 
nating in  muscular  tissues;  (2)  a  class 
composed  of  bodies  which  resemble  in 
their  constitution  and  reactions  the  alka- 
loids, having  a  marked  degree  of  l.oxic 
effect  resembling  muscle-toxins.  Dubois 
(Arch,  de  Phys.  Norm,  et  Path.,  vol.  viii, 
p.  412,  '90). 

The  active  substance  contained  in  the 
medullary  portion  of  the  capsule  and  the 
activity  of  the  extract  shown  to  run 
parallel  with  the  distinctness  of  certain 
color-reactions  (e.g.,  a  green  with  ferric 
chloride),  which  are  due  to  a  substance 
which  has  not  yet  been  isolated  in  a  pure 
state.     Fraenkel   (Wiener  med.  Bl.,  '9G). 

Experiments  showing  that  after  sec- 
tion of  the  medulla  and  extirpation  of 
the  spinal  cord,  the  injection  of  suprar- 
enal extract  is  capable  of  prolonging  life 
of  the  animal,  which  would  otherwise 
quickly  succumb.  Strickler,  in  1877, 
proved  that  extirpation  of  both  the  cer- 
vical and  thoracic  parts  of  the  spinal 
cord  caused  instantaneous  stoppage  of 
the  heart's  action.  Biedl  (Lancet,  Mar. 
21,  '96). 

The  marked  stimulation  of  the  heart 
and  arterioles  is  probably  due  to  an 
action  on  their  intrinsic  nervous  ganglia 
rather  than  to  a  direct  action  on  the 
muscular  fibres.  As  previously  observed 
by  Cybulski,  administration  of  the  ex- 
tract by  the  mouth   or   subcutaneously 


396 


ANIMAL  EXTRACTS.  SUPRARENAL  EXTRACT. 


has  very  little  effect  on  the  circulation 
as  compared  to  what  is  observed  after 
intravenous  injection.  Obviouslj',  the 
active  principle  is  destroyed  by  the  tis- 
sues. Gottlieb  (Arch.  f.  Exper.  Path.  u. 
Pharm.,  B.  38,  '96). 

Researches  into  the  constitution  of  the 
blood-pressure-raising  constituent  of  the 
suprarenal  capsule  showing  that  it  is 
to  be  classed  with  the  pyridine  bases  or 
alkaloids,  and  that  it  is  not  possible  to 
split  off  pyrocatechin  from  the  isolated 
active  principle.  This  view  is  the  op- 
posite of  that  of  Mtihlmann,  who  sup- 
posed that  the  blood-pressure-raising 
constituent  was  pyrocatechin  joined  to 
some  other  substance,  probably  an  acid. 
Abel  and  Crawford  (Johns  Hopkins 
Hosp.  Bull.,  vol.  viii,  p.  151,  '97). 

The  extraordinary  rise  in  the  blood- 
pressure  after  intravenous  injection  of 
suprarenal  extract  is  due  to  stimulation 
of  the  vasoconstrictor  nerves :  the  centres 
in  the  brain  as  well  as  the  ganglia  in 
the  blood-vessels.  The  suprarenal  extract 
paralyzes  the  vagus  nerve  and  the  car- 
diac depressor.  It,  on  the  other  hand, 
stimulates  the  central  as  well  as  periph- 
eral ends  of  the  accelerators.  The  tem- 
porary retardation  of  the  heart-beat  is 
produced  by  the  momentary  stimulation 
of  the  pituitary  body,  which  is  brought 
about  by  the  sudden  rise  of  the  blood- 
pressure  in  the  skull.  Cyon  (Pflueger's 
Arch,  of  Phys.,  vol.  Ixii,  p.  370,  '98). 

The  two  drugs  which  most  promote 
contraction  of  the  arteries,  and  in  conse- 
quence must  antagonize  the  dangerous 
fall  of  blood-pressure  produced  by  chloro- 
form, are  atropine  and  extract  of  supra- 
renal capsule.  Extract  of  suprarenal  cap- 
sule remarkably  increases  the  rate  and 
the  force  of  the  heart-beat.  Schafer 
(Lancet,  Feb.  5,  '98). 

The  most  useful  application  of  the 
suprarenal  extract  will  be  in  cases  of 
cardiac  weakness  and  threatening  col- 
lapse. Mankovsky  (Russian  Arch,  of 
Path.  Clin.  Med.  and  Bact.,  Mar.,  '98). 

The  medulla  of  suprarenal  capsules 
contains  a  chromogen,  possibly  allied  to 
tannin  in  coffee,  and  an  active  principle 
which  chemically  appears  to  be  closely 
connected  with  piperidine.  This  latter 
has  a  remarkable  effect  upon  the  mus- 


cular tissues,  generally  increasing  their 
tone,  and  producing,  when  injected  in- 
travenously, an  enormous  rise  in  blood- 
pressure.  Swale  Vincent  (Birmingham 
Med.  Rev.,  vol.  xliii.  No.  236). 

Experiments  of  Biedl  and  of  Gottlieb 
repeated.  Conclusion  that  the  use  of 
suprarenal  gland  in  the  lower  animals 
does  much  toward  preventing  accidents 
during  the  administration  of  chloroform, 
probably  through  its  powerful  influence 
on  the  vascular  system.  Minkowsky 
(Revue  de  Ther.  Med.-chir.;  Ther.  Gaz., 
Dec.  15,  '98). 

Suprarenal  extract  in  dogs  stimulates 
the  vagus  centre,  thus  inhibiting  the 
heart.  It  produces  also  a  direct  stimula- 
tion of  the  heart-muscle,  resulting,  when 
the  vagus  influence  is  removed,  in  an  in- 
crease in  the  force  and  frequency  of  its 
beat.  Accompanying  the  heart-action 
there  occurs  a  rise  in  the  systemic  blood- 
pressure  due  to  the  contraction  of  the 
arterioles.  The  pressure  in  the  pulmo- 
nary arteries,  however,  is  not  raised, 
these  vessels  not  being  acted  upon  as  are 
tlie  others.  Wallace  and  Mogt  (Boston 
Med.  and  Surg.  Jour.,  Jan.  26,  '99). 

Epinephrin,  the  active  principle  of  the 
adrenals  and  the  commercial  adrenalin, 
may  practically  be  considered  alike. 
Injected  subcutaneously,  intravenously, 
intraperitoneally,  or  into  the  spinal 
canal,  epinephrin  in  large  doses  causes 
repeated  vomiting,  excitement,  and  gen- 
eral weakness,  which  may  end  in  com- 
plete prostration,  bloody  diarrhoea,  and 
death.  The  findings  at  autopsy  are 
characteristic.  Death  may  be  caused 
by  cardiac  or  respiratory  paralysis  or 
by  both.  The  lethal  dose  lies  between 
1  and  2  milligrammes,  per  kilogramme, 
intravenously.  The  subcutaneous  lethal 
dose  lies  between  5  and  6  milligrammes, 
the  intraperitoneal  between  0.5  and  O.S 
milligramme.  S.  Amberg  (Arch.  In- 
ternat.  de  Pharmacodj^n.,  vol.  xi,  fase. 
1  and  2,  1902). 

Prolonged  contact  of  the  blood  with 
the  extract  does  not  deprive  the  latter 
of  its  effect  on  the  blood-pressure.  In- 
travenous injections  of  adrenalin  in  rab- 
bits in  which  the  blood-vessels  of  one 
ear  were  deprived  of  the  vasomotors 
showed   a  blanching  of  the   ear   of  the 


ANIMAL  EXTRACTS.  SUPRARENAL  EXTRACT. 


397 


operated  side  which  lasted  longer  than 
that  on  the  normal  side.  Following 
this  the  normal  ear  became  perceptibly 
more  congested  than  before  the  injec- 
tion. This  seems  to  show  that  the  ex- 
tract favors  vasodilation  when  the  cen- 
tral nervous  influence  is  intact;  when 
the  latter  is  absent,  constriction  results. 
The  authors  also  demonstrated  that  sub- 
cutaneous injection  in  the  normal 
animal  had  no  effect  on  the  pupil  and 
very  little  constricting  effect  on  the 
blood-vessels,  but  when  the  sympathetic 
nerve  was  cut  the  pupil  remained  dilated 
for  a  considerable  time,  and  vascular 
constriction  also  lasted  for  an  equal 
period.  S.  J.  and  C.  Meltzer  (Amer. 
Med.,  Feb.  7,  1903). 

Therapeutics.  —  Suprarenal  therapy 
has  now  exceeded  thyroid  therapy  in  far- 
reaching  application.  Indeed,  supra- 
renal extractives  seem  endowed  with 
properties  which  Bates  summarizes  by 
the  word  ''marvelous."  Unlike  other  po- 
tent agents,  they  are  devoid  of  pernicious, 
after-effects.  The  author  just  named 
states,  for  example,  that,  while  we  expect 
great  dilatation  of  blood-vessels  to  follow 
powerful  contraction,  "in  2000  cases 
noted  in  which  the  suprarenal  produced 
this  contraction  the  expected  dilatation 
did  not  occur.'"'  Again,  though  a  drug 
which,  in  minute  doses,  produced  power- 
ful effects  is  deemed  a  poison,  such  can- 
not be  said  of  pure  adrenal  products. 
"No  untoward  effect,"  he  writes,  "has 
ever  followed  the  local  or  internal  ad- 
ministration of  the  untainted  gland. 
Two  pounds  of  the  fresh  suprarenal  cap- 
sule in  the  form  of  an  aqueous  extract 
has  been  swallowed  without  any  apparent 
ill  effects."  Its  application  to  the  eye 
does  not  cause  irritation,  and  it  does  not 
cause  dilatation  or  contraction  of  the 
pupil.  It  is  not  cumulative  when  taken 
internally,  and  it  does  not  possess  at- 
tributes which  involve  the  danger  of  a 
"habit,"  as  do  cocaine,  alcohol,  etc. 

We  cannot  agree  with  Dr.  Bates  when 


he  states  that  no  untoward  effects  ever 
follow  the  local  use  of  adrenal  extract. 
There  sometimes  occurs  overdistension 
of  the  sinuses  of  the  turbinals,  for  in- 
stance, as  noted  by  Kyle  and  others,  and 
secondary  haemorrhage  is  more  likely  to 
follow  its  use. 

The  extract,  applied  locally,  reduces 
congestion  and  is  of  especial  benefit  in 
rhinitis  and  hay  fever.  Eye:  Local  ap- 
plication lessens  congestion  in  conjuncti- 
vitis, keratitis,  and  iritis,  and  hastens  the 
absorption  of  inflammatory  tissue.  In 
lacrymal  stricture  and  abscess  the  writer 
injects  a  solution  of  the  extract  through 
the  "puncta."  The  vascularity  is  rapidly 
diminished,  and  any  pus  present  may  be 
expressed  via  the  canal.  Ear:  Locally 
applied  to  the  Eustachian  tube,  the  con- 
gestion is  reduced  and  deafness  and  tin- 
nitus disappear.  Its  haemostatic  proper- 
ties are  well  known,  and  it  can  be  used 
thus  with  confidence,  as  no  clots  are 
formed.  In  Addison's  disease  and 
asthma  it  has  given  good  results,  and  2 
grains  of  the  dried  extract  internally  in 
exophthalmic  goitre  will  lessen  the  heart- 
rate  and  decrease  the  size  of  the  thyroid. 
The  normal  heart  is  not  affected  when 
•given  internally,  neither  the  normal 
blood-pressure  nor  pulse,  but  an  inter- 
mittent pulse  becomes  regular,  a  weak 
pulse  stronger,  and  feeble  cardiac  muscle 
remarkably  stimulated.  All  the  effects 
produced  are  only  temporary,  so  that  re- 
peated applications  are  necessary.  But 
in  all  forms  of  inflammation  it  is  very 
useful  in  reducing  tension  and  allaying 
pain.  Bates  (Med.  News,  p.  441,  Mar., 
1900). 

After  the  use  of  suprarenal  extract 
there  is  danger  of  secondary  haemor- 
rhages, which  come  on  several  hours 
after  the  operations,  and  are  often  so  pro- 
fuse as  to  alarm  the  patient.  Conclu- 
sions are  that  there  is  a  likelihood  of 
having  more  profuse  secondary  haemor- 
rhages after  the  use  of  cocaine  and 
suprarenal  extract  than  after  the  use  of 
cocaine  alone.  F.  E.  Hopkins  (Phila. 
Med.  Jour.,  May  5,  1900). 

This  does   not,    however,   reduce   the 
therapeutic  value  of  adrenal  extractives. 


398 


ANIMAL  EXTRACTS.     SUPRARENAL  EXTRACT.     ADDISON'S  DISEASE. 


Solutions  of  adrenal  extract,  or  of  its 
more  conyenient  preparations  on  the 
market  (epinephrin,  adrenalin,  etc.),  in 
1  to  1000  or  1  to  5000  solution  arrest 
epistaxis  and  limit  haemorrhage  during 
intranasal  operations,  while  greatly  in- 
creasing the  operative  field  by  contract- 
ing the  tissues.  The  solution  is  to  be  ap- 
plied with  a  pledget  of  cotton  and  left 
in  situ  about  five  minutes,  when  the  tis- 
sues are  blanched  and  ready  for  operative 
work.  It  may  also  b*  applied  in  the 
form  of  a  spray  in  hay  fever  and  local  in- 
flammatory disorders,  1  part  of  adrenalin 
in  6  of  the  normal  salt  solution  is  to  be 
preferred  in  the  latter. 

Thirtj'-five  cases  in  tabulated  form, 
showing  that  the  useful  effects  of  the 
suprarenal  gland  were  obtained.  In  two 
eases  the  nose  was  not  packed,  but  the 
patients  were  placed  in  bed  and  kept 
quiet  for  two  days  and  adrenalin,  1  to 
10,000,  was  applied  by  means  of  spray 
every  two  hours.  There  was  no  sub- 
sequent haemorrhage  in  either  of  these 
cases.  The  author  has  employed  no 
suprarenal  extract  since  taking  up  the 
use  of  adrenalin.  Emil  Mayer  (Phila. 
Med.  Jour.,  April  27,  1901). 

Great  relief  and  almost  complete  com- 
fort from  the  topical  use  of  adrenalin 
solution  applied  on  a  cotton  wad,  or  as 
a  spray  in  the  proportion  of  1  to  5000. 
S.  Solis-Cohen  (Amer.  Med.,  Sept.  7, 
1901). 

The  following  solution  is  a  valuable 
local  application  in  hay  fever,  and  is 
also  remarkably  efficient  in  controlling 
inflammation  or  bleeding  and  in  produc- 
ing anaesthesia  of  the  mucous  mem- 
brane:— 

IJ  Adrenal,  20  grains. 
Phenic  acid,  2  grains. 
Eucaine-B,  5  grains. 
Distilled  water,  2  drachms. 
Macerate  ten  minutes;    filter. 
This  solution  is  permanent,  will  not 
decompose    nor    lose    its    physiological 
activity    for    several    months.     Somers 
(Merck's  Archives,  June,  1900). 

The  best  way  of  applying  solution 
adrenalin  chloride  is  in  conjimction  with 


a  2-per-eent.  solution  of  cocaine.  In 
the  nose  a  pledget  of  cotton  saturated 
with  a  2-per-cent.  solution  of  cocaine 
should  be  allowed  to  remain  in  contact 
with  the  tissues  not  longer  than  two 
minutes,  and  its  use  .should  be  imme- 
diately followed  by  the  similar  applica- 
tion of  solution  adrenalin  chloride. 
Prior  to  operative  procedures  the  1  to 
1000  or  the  1  to  2000  solution  should 
be  employed ;  for  the  relief  of  local  con- 
gestion the  1  to  10,000  will  give  the 
most  satisfactory  results.  The  adre- 
nalin pledget  should  be  left  in  contact 
Avith  the  tissues  for  ten  to  fifteen 
minutes,  depending  upon  the  result  de- 
sired, as  well  as  the  amount  of  swelling 
to  be  reduced.  D.  Braden  Kyle  (Therap. 
Gaz.,  .July  1.5,  1902). 

In  cases  of  obstruction  from  any  cause 
the  nasal  passage  is  packed  with  cot- 
ton-wool saturated  with  adrenalin- 
chloride  solution.  When  the  swelling- 
lias  been  reduced  the  membrane  should 
be  cocainized  and  the  passages  explored, 
until  the  cause  of  the  trouble  is  located, 
when  the  operation  may  be  performed 
with  safety.  D.  S.  Reynolds  (Med. 
Mirror,  Aug.,  1902). 

In  pharyngeal  and  laryngeal  inflam- 
mations a  solution  of  1  to  10,000,  grad- 
ually increased  to  a  1  to  2000,  is  often 
of  advantage  applied  in  the  form  of  a 
fine  spray.  It  may  also  be  painted  over 
inflamed  tonsils  with  a  camel's-hair  pen- 
cil or  a  pledget  of  absorbent  cotton. 

Case  of  chronic  laryngitis  in  which  1 
to  10,000  normal  salt  solution  of  ad- 
renalin chloride  was  applied  two  or 
three  times.  In  the  course  of  five 
minutes  the  congestion  had  been  con- 
siderably reduced ;  the  blanching  process 
did  not  extend  at  all  beyond  the  parts 
actually  touched. 

Case  of  acute  laryngitis  with  oedema 
of  the  glottis,  in  which  there  was  great 
swelling  and  redness  of  the  epiglottis, 
with  difficult  respiration,  which  seemed 
likely  to  necessitate  a  speedy  trache- 
otomy. The  interne  was  directed  to 
apply  to  the  larynx,  every  tlu'ee  or  four 
hours,  a  spray  of  1  part  of  adrenalin 
to  10,000  normal  salt  solution.  This 
was  done,  with  the  effect  of  giving  the 


ANIMAL  EXTRACTS.     SUPRARENAL  EXTRACT.     ADDISON'S  DISEASE. 


399 


patient  speedy  relief.  He  said  that  he 
felt  as  though  the  parts  had  been  con- 
tracted. In  addition  to  this  treatment 
the  patient  was  given  i  /  grain  of  ni- 
trate of  pilocarpine,  which  caused  free 
salivation  and  profuse  sweating.  This 
was  repeated  twice  a  day  for  two  days; 
therefore  it  cannot  be  said  just  what 
the  influence  of  the  adrenalin  was;  how- 
ever, its  immediate  effects  were  good, 
as  demonstrated  several  times.  The  pa- 
tient made  a  speedy  recovery.  E. 
Fletcher  Ingals  (Jour.  Amer.  Med.  As- 
soc., April  27,  1901). 

A  few  minutes'  application  of  a  solu- 
tion of  adrenalin  chloride  (1  to  1000) 
to  tlie  mucosa  of  the  respiratory  tract 
makes  possible  an  absolutely  bloodless 
operation;  its  value  as  an  adjunct  in 
operative  procedures  cannot  be  over- 
estimated. It  has  a  wide  field  of  use- 
fulness as  a  therapeutic  agent  because 
of  its  rapid  and  safe  contraction  of  the 
superficial  capillaries.  The  author  has 
found  the  1  to  1000  solution  useful  iii 
acute  and  subacute  laryngitis,  especially 
in  the  ease  of  vocalists.  A  simple  con- 
gestion of  the  larynx  may  be  reduced 
readily  and  vocalization  restored  with- 
out discomfort  or  irritation.  il.  A. 
.  Goldstein  (St.  Louis  Med.  Rev.,  Aug.  10, 
1902). 

Internal  Administration. — Suprarenal 
substance  and  extractives  have  been  nsecl 
internally  witli  more  or  less  advantage  in 
inflammatorj'  disorders  of  the  respiratory 
and  cardiac  systems,  inclnding  asthma, 
bronchitis,  hemoptysis,  and  in  exoph- 
thalmic goitre,  malaria,  diabetes,  and 
mental  disorders.  As  is  the  case  with 
thyroid  substance  and  its  extractives,  su- 
prarenal substance  and  its  extracts  are 
not  destroyed  in  the  digestive  process. 

The  use  of  suprarenal  powder  in  dis- 
eases of  the  heart  in  one  hundred  cases 
warranted  the  following  conclusions: 
After  the  administration  of  the  supra- 
renal powder  the  following  was  ob- 
served: 1.  A  weak  and  irregular  acting 
heart  became  stronger  and  more  regu- 
lar. 2.  A  dilated  heart  was  contracted. 
3.  A  diffused  apex-beat  became  localized. 


4.  A  diffused,  loud,  and  rough  mitral 
regurgitant  murmur  became  localized, 
smoother,  and  lessened  in  intensity, 
while  in  some  cases  the  murmur  disap- 
peared. 5.  A  murmur  which,  owing  to 
the  extreme  weakness  of  the  heart, 
could  scarcel}'  be  heard,  became  more 
distinct,  thus  aiding  in  the  diagnosis. 
6.  The  normal  cardiac  sounds,  when  dis- 
tinct, became  clearer  and  more  easily 
distinguished.  7.  In  some  cases  a  rapid 
pulse  became  less  rapid;  in  other  cases 
a  slow  pulse  became  faster.  8.  Patients 
who  were  very  weak,  with  organic  heart 
disease,  were  improved.  9.  No  effect 
was  observed  in  organic  heart  disease 
when  the  pulse  was  strong  and  regular. 
Three  grains  of  the  powder  were  found 
effective,  but  larger  doses  proved  harm- 
less. Samuel  Floersheim  (New  York 
Med.  Jour.,  May  4,  1901). 

Two  cases  in  which  suprarenal  extract 
proved  effective  when  other  remedies 
had  failed.  One  patient  was  a  woman 
aged  82,  suffering  from  mitral  insuffi- 
ciency with  swollen  extremities,  gastric- 
irritability,  and  other  symptoms  of  car- 
diac failure.  She  had  received  digitalis, 
caffeine,  strophanthus,  etc.,  with  unsat- 
isfactory results.  Suprarenal  extract 
was  given  in  3-grain  doses,  thrice  daily 
after  meals.  Prompt  and  continuous 
improvement  followed,  the  cedema  disap- 
peared, vomiting  ceased,  and  the  patient 
could  soon  resume  her  walks.  The  sec- 
ond case,  a  man  of  76,  had  swollen  feet, 
and  a  cardiac  lesion  was  suspected. 
The  usual  heart-tonics  failed  to  give  re- 
lief, until  suprarenal  extract  was  tried, 
and  almost  immediate  amelioration 
resulted.  Six  weeks  later  all  oedema 
Avas  gone.  The  tonic  influence  of  the 
remedy  on  the  vascular  system  was 
marked.  W.  E.  Decks  (Montreal  Med. 
•Jour.,  Nov.,  1901). 

The  chief  physiological  action  of 
suprarenal-gland  extracts  is  increase  of 
arterial  pressure,  but  they  also  produce 
a  tonic  effect  upon  the  heart  and  on 
muscle  generally  and  possibly  some 
diminution  of  metabolism.  Owing  to 
the  transitory  nature  of  the  effects  pro- 
duced by  intravenous  injection  of  the 
extracts,  they  must  be  given  by  the 
mouth  if  any  prolonged  action  is  to  be 


400 


ANIMAL  EXTRACTS.  SUPRARENAL  EXTRACT.  OPHTHALMOLOGY. 


obtained.  Digestion  is  not  impaired  by 
moderate  doses.  Both  for  a  •priori  rea- 
sons and  as  a  matter  of  experience  they 
appear  to  be  indicated  in  conditions  of 
excitement  and  exaltation,  in  which 
state  the  blood-pressure  is  usually  low- 
ered. In  mental  diseases  administration 
for  a  certain  length  of  time  will  be 
found  necessary  in  most  cases  to  pro- 
duce marked  effect  where  excitement  is 
violent.  Although  the  state  oi  the  blood- 
pressure,  as  a  rule,  forms  a  conven- 
ient indication  for  their  use,  high  press- 
ure does  not  absolutely  contra-indicate 
them,  if  there  is  some  reason  to  think 
that  it  is  not  associated  with  the  mental 
state,  as  an  abnormally  high  pressure 
may  still  be  lower  than  the  average  of 
an  individual  case.  Suprarenal  extracts 
seem  unlikely  to  be  of  benefit  in  eases 
of  melancholia  and  where  there  is  much 
stupor.  It  therefore  seems  probable,  on 
the  whole,  that  the  psychoses  in  which 
this  will  be  found  most  useful  is  in  acute 
mania  of  fairly  recent  origin  uncom- 
plicated by  stupor.  W.  R.  Dawson 
(.Jour.  Mental  Science,  Oct.,   1901). 

Addison's  Disease.  — •  Imperfect  ac- 
tion of  the  suprarenal  capsiiles  implying, 
in  the  light  of  our  present  knowledge, 
a  gradual  toxemia  by  the  products  of 
metabolism;  it  was  thought  that  the  in- 
gestion of  the  organ  or  its  extracts  would 
prove  curative.  So  far,  no  cases  of  final 
cure  can  be  said  to  have  been  witnessed, 
but  several  cases  have  remained  well  un- 
der the  continued  use  of  the  remedy  for 
a  considerable  time;  some  of  these,  how- 
ever, have  had  sudden  recurrences,  ter- 
minating fatally.  It  is  quite  evident  that 
the  entire  question  is  still  very  obscure, 
but  it  is  also  certain  that  the  use  of 
adrenal  or  its  preparation  merits  further 
trial,  especially  in  the  earlier  stages  of 
the  disease  and  when  the  presence  of  a 
tubercular  process  cannot  be  absolutely 
recognized. 

Ophthalmology.  —  In  inflammatory 
diseases  of  the  eye,  the  active  principles 
of  suprarenal  have  the  power  of  suddenly 


stimulating  the  vasomotors,  thus  deplet- 
ing the  engorged  vessels.  In  a  method 
recommended  by  Barraud,  sheep-capsules 
are  used,  and  with  the  product  of  evapo- 
ration a  solution  is  prepared  with  equal 
quantities  of  sterilized  water;  this  is 
done,  as  much  as  possible,  at  the  time  of 
using,  for  the  solution  becomes  rapidly 
altered.  One  drop  of  Barraud's  suprar- 
enal solution  instilled  into  the  eye  pro- 
duces an  energetic  vasoconstriction  of 
the  conjunctiva  at  the  end  of  thirty  to 
forty  seconds.  In  a  few  minutes  this 
action  is  sufficiently  marked  to  cause 
pallor  of  the  mucous  membranes,  and 
continues  about  twenty  minutes,  after 
which  the  vessels  return  to  their  former 
condition. 

In  an  inflamed  conjunctiva,  the  pain 
and  redness  completely  disappear  for  the 
time  being.  Its  application  causes  no 
pain  even  when  the  congestion  of  the 
eye  renders  it  hyperassthetic. 

In  ophthalmology,  therefore,  the  aque- 
ous extract  of  suprarenal  capsules  flnds 
its  application  as  follows:  1.  In  con- 
junctivitis, kerato-conjunctivitis,  vascu- 
lar keratitis,  episcleritis,  and  glaucoma 
as  an  aid  to  the  usual  medication.  2. 
In  cases  in  which  extreme  inflammation 
of  the  tissues  and  intense  congestion  of 
the  media  of  the  eye  limit  the  action  of 
cocaine,  it  regains  its  analgesic  power, 
owing  to  the  ischsemia  previously  pro- 
duced by  the  suprarenal  extract.  3. 
Finally,  whenever  there  is  reason  to  fear 
a  hsemorrhage  during  surgical  interven- 
tion on  the  eye,  the  extract  acts  either 
as  a  preventive  or  as  a  radical  htemo- 
static  agent.    (Maurange.) 

Dor  was  first  to  recommend  the  ap- 
plication of  suprarenal  extract  in  cases 
where,  an  operation  being  urgent,  it  was 
difficult  to  obtain  local  anesthesia  with 
cocaine  alone,  owing  to  hyperemia  of 
the  conjunctiva.     (Darier.) 


ANIMAL  EXTRACTS.  SUPRARENAL  EXTRACT.  NEURASTHENIA. 


401 


The  method  for  preservation  of  suprar- 
enal solutions  employed  for  over  a  year 
now  in  Buffalo  with  excellent  satisfac- 
tion is  as  follows:  One-half  gramme  of 
the  extract  of  suprarenal  capsule  is 
rubbed  to  a  paste,  the  water  is  added 
gradually  until  there  is  a  solution  of  1 
ounce.  This  is  then  heated  for  some  time 
to  160°  F.  Water  being  constantly  added 
as  the  solution  evaporates  so  as  to  keep 
the  amount  of  liquid  always  up  to  1 
ounce.  Fifteen  grains  of  boric  acid  are 
then  added  and  the  solution  is  ready.  It 
will  keep  for  weeks.  The  suprarenal  ex- 
tract is  used  in  the  eye  in  the  shape  of 
small  wafers.  To  make  these  the  extract 
is  rubbed  up  into  a  paste  and  then  mu- 
cilage added  to  give  it  consistency. 
These  feel  somewhat  rough,  but  are  un- 
irritating  when  moistened.  The  addition 
of  formalin,  1  to  10,000  or  the  employ- 
ment of  a  concentrated  extract  in  glyc- 
erin diluted  as  required  are  good  methods 
for  preserving  the  substance.  But  both 
the  formalin  and  the  glycerin  have 
proved  irritating  to  some  eyes.  Lucien 
Howe  (Med.  News,  Mar.  24,  1900). 

Adrenalin  may  be  employed  in  very 
ailute  solutions  in  the  form  of  a  collyr- 
iiun  with  boric  acid.  One  drachm  of 
the  1  to  1000  solution  in  2  ounces  of 
distilled  water,  with  10  grains  of  boric 
acid,  is  effectual  when  frequently  used. 
To  relieve  the  congestion,  irritation,  and 
lacrymation  caused  by  ordinary  con- 
junctivitis, and  to  combat  blepharo- 
spasms. To  relieve  trachomatous  pan- 
nus.  To  enhance  the  action  of  cocaine, 
atropine,  eserine,  and  pilocarpine,  by 
promoting  their  absorption.  Adrenalin 
is  first  used,  followed  during  the  period 
of  blanching  by  the  drugs  named.  To  re- 
duce the  tension  in  trachoma.  To  facil- 
itate the  introduction  of  lacrymal 
sounds,  the  solution  being  first  injected 
into  the  ductus  ad  nasum.  To  relieve 
ciliary  pain  in  keratitis,  iritis,  and  cy- 
clitis  with  glaucoma.  To  modify  opac- 
ities of  the  cornea.  To  produce  cosmetic 
effect.  G.  E.  de  Schweinitz  (Therap. 
Gaz.,  July  15,  1902). 

Genito-itrinaey  Diseases. — In  dis- 
orders of  the  urethra  and  Tulva  supra- 
renal extract  has  recently  been  found  of 

1- 


considerable  value.  Its  effects  are  sim- 
ilar to  those  produced  upon  the  tissues 
of  the  upper  respiratory  tract.  A  1  to 
10,000  solution  was  also  found  by  Fritsch 
greatly  to  facilitate  cystoscopy  and  op- 
erative procedures  in  the  bladder. 

In  chronic  urethritis  involving  the 
glands  and  follicles  in  the  anterior 
urethra  the  extract  of  suprarenal  gland 
is  of  marked  therapeutic  value.  It  acts 
not  as  an  astringent,  but  as  a  direct 
stimulant  to  the  muscular  coats  of  the 
blood-vessels.  Absorption  of  embryonic 
tissue  is  thus  brought  about,  and  im- 
provement of  the  general  tone  takes 
place.  Three  cases  are  reported  in  which 
chronic  urethritis  was  cured  by  the  use 
of  a  solution  containing  the  extract.  In 
one  ease  of  chronic  posterior  urethritis 
local  applications  through  the  endo- 
scopic tube  of  a  10-per-cent.  solution, 
daily  are  said  to  have  practically  cured 
the  disease  after  fifteen  days  of  this 
treatment.  In  the  ordinary  cases  of 
chronic  anterior  urethritis  the  remedy 
was  applied  by  means  of  a  hand-syringe. 
Eaton  (Occid.  Med.  Times,  March,  1902). 
Adrenalin  is  indicated  in  cases  of 
mucous  or  muco-purulent  discharge; 
when  the  urine  shows  mucus  or  flat, 
scaly  shreds  and  mucous  shreds;  when 
endoscopical  examination  shows  gran- 
iilar  patches  or  superficial  scleroses; 
when  pus-cells,  epithelium,  mucous  gon- 
ococei,  or  other  micro-organisms  are 
present.  Series  of  cases  of  urethritis 
which  had  resisted  other  drugs,  and 
which  were,  with  few  exceptions,  bene- 
fited by  instillations  of  adrenalin  chlo- 
ride, 1  to  1000.  The  field  of  usefulness 
of  this  drug  in  urethral  work  is  limited 
to  the  same  indications  as  for  mucous 
membranes  in  other  localities.  It  is 
painless  to  apply,  and  causes  a  cessa- 
tion of  secretion  by  contraction  of  the 
blood-vessels  for  a  varying  time.  It  will 
only  act,  however,  on  superficial  lesions, 
and  will  bear  watching  for  untoward 
action.  S.  E.  Gans  (Phila.  Med.  Jour., 
Dec.  13,  1902). 

In  two  cases  of  pudendal  irritation, 
attended  with  marked  pruritus,  supra- 
renal extract  gave  marked  relief.  In 
the   one,   a   young  woman   18   years   of 


403 


ANIMAL  EXTRACTS.    PITUITARY  EXTRACT. 


age,  violent  itching  of  the  vulva  and 
anus  had  come  on  ten  days  before.  Not- 
withstanding usual  methods  of  treat- 
ment, there  was  no  relief,  and  in  the 
meantime  the  condition  had  become  so 
severe  that  she  was  unable  to  leave  the 
house.  A  local  examination  showed  an 
intensely  congested  condition  of  the 
vulva  and  the  lower  part  of  the  vagina, 
with  increased  secretion.  A  strong  solu- 
tion of  suprarenal  extract  was  applied 
to  the  part,  which  was  followed  by  a 
rapid  blanching  of  the  mucous  mem- 
brane. Momentarily  the  itching  was  in- 
creased, and  then  gave  way  to  a  slight 
burning  sensation,  which  passed  oflf  in 
a  few  minutes.  The  effect  of  this  appli- 
cation lasted  for  fourteen  hours,  when 
the  itching  recurred.  A  second  applica- 
tion cured  the  case.  F.  S.  Meara 
(Merck's  Archives,  May,  1902). 

Pituitary  Extract. 

Lesions  of  the  pituitary  body  having 
been  found  in  almost  all  autopsies  in 
cases  of  acromegaly,  a  close  connection 
between  this  organ  and  the  symptoms 
of  the  disease  could  but  be  inferred;  it 
also  suggested  the  use  of  the  gland  as 
a  remedial  agent  soon  after  the  animal 
extracts  entered  the  field  of  therapeutics. 

Physiological  Action. — Although 
Mairet  and  Bosc  found  that  triturated 
or  macerated  gland  was  practically  inert 
in  man  as  well  as  animals,  producing  rise 
of  temperature  and  emaciation,  Schafer 
and  Oliver  found,  to  the  contrary,  that 
it  was  quite  active,  affecting  mainly  the 
arterioles  and  heart-muscle.  It  is  thought 
to  bear  some  undetermined  relation  to 
the  nutrition  of  bone  or  dermal  tissues. 

Rapid  and  great  rise  of  blood-pressure 
observed,  bearing  directly  upon  the 
arterioles  and  probably  upon  the  heart- 
muscles.  The  pituitary  body  furnishes 
a  secretion  to  the  blood  which  serves  to 
increase  the  contractile  power  of  the 
heart  and  arteries  and  to  influence  the 
nvitrition  of  certain  tissues.  Schafer  and 
Oliver   (Jour,  of  Phys.,  p.  277,  '95). 

In    animals    (rabbits),    excepting    dis- 


turbances evidently  due  to  local  infec- 
tion produced  by  the  subcutaneous  in- 
jections, very  slight  effects  were  ob- 
tained: a  transient  elevation  of  tempera- 
ture, most  marked  two  hours  after  the 
injection.  Injected  into  the  veins  it 
produced  disturbances  similar  to  those 
obtained  after  injection  of  blood,  namely: 
death  from  coagulation.  If  treated  by 
sodium  chloride  or  by  heat  it  produces 
results  similar  to  those  of  blood-serum 
when  similarly  treated,  but  it  is  dis- 
tinguished only  by  a  more  marked  my- 
osis;  and  given  by  the  mouth,  macerated 
or  triturated  pituitary  gland  causes, 
besides  a  slight  elevation  of  temperature, 
a  noticeable  gastro-intestinal  disturbance 
and  a  temporary  albuminuria,  showing 
that  this  substance  possesses  only  a 
slight  degree  of  toxicity.  With  dogs 
nothing  of  impoi-tance  is  noticed:  slight 
emaciation  and  slight  elevation  of  tem- 
perature. With  healthy  men  the  same 
results  were  reached.  Mairet  and  Boso 
(Arch,  de  Phys.,  No.  3,  p.  600,  '96). 

It  is  probable  that  the  pituitary  gland 
bears  some  unascertained  relation  to  the 
nutrition  of  bony  and  dermal  tissues, 
as  a  result  of  which  an  overgrowth  of 
them  accompanies  changes  in  the  gland 
which  presumably  affect  its  functions. 
Whether  or  not  these  changes  are  pri- 
mary is  yet  unknown.  F.  P.  Kinnicutt 
(Amer.  Jour.  Med.  Sciences,  July,  '97). 

The  pituitary  gland  is  a  functional 
organ,  disturbances  of  the  metabolism  of 
which  are  the  principal  factors  in  both 
acromegaly  and  giantism,  the  differences 
between  the  results  being  due  to  the 
stage  of  individual  development  at  which 
the  disturbance  of  function  begins. 
Woods  Hutchinson  (N.  Y.  Med.  Jour.,, 
July  21  and  28,  1900). 

Therapeutics. — In  acromegaly  it  can- 
not be  said  to  have  done  much  more  than 
to  relieve  some  of  the  active  symptoms 
and  to  have  contributed  to  the  patient's 
comfort.  This  means  considerable  in 
these  cases,  which  sometimes  suffer 
greatly  from  neuralgic  pains,  violent 
headaches,  etc. 

Statistics  of  13  cases  of  acromegaly 
treated  with  pituitary  preparations:    In 


ANIMAL  EXTRACTS.     SPLENIC  EXTRACT. 


403 


7  cases  varying  degrees  of  improvement 
were  noted.  In  1  of  these  the  improve- 
ment occurred  under  the  combined  use 
of  pituitary  and  thyroid  preparations. 
In  5  eases  no  eflfect  wr.s  obtained;  and 
in  1  case  the  patient  was  made  worse  by 
the  treatment.  F.  P.  Kinnicutt  (Amer. 
Jour.  Med.  Sciences,  July,  '97). 

Administration  of  tlie  tablets  for 
months  at  a  time  having  failed  to  amelio- 
rate the  symptoms  of  acromegaly  in  per- 
sonal cases,  and  the  fact  that  extirpation 
of  the  pituitary  gland  in  dogs  and  in 
man  (when  the  hypophysis  cerebri  has 
been  the  seat  of  a  destructive  process, 
such  as  sarcoma)  is  not  followed  by  any 
of  the  pathognomonic  symptoms  of  acro- 
megaly, Avould  seem  to  prove  that  acro- 
megaly is  not  due  to  obliteration  of  the 
glandular  structure  of  the  hypophysis, 
and  that  this  alleged  remedy  has  been 
used  only  empirically  and  is  absolutely 
inefficacious.  W.  M.  Lesz}'nslcy  (Med. 
Record,  June  30,  1900). 

Organic  Extracts. 

Preparations  of  the  various  organs,  the 
spleen,  the  ovaries,  hone-marrow,  the  tes- 
ticles, the  brain  and  nerves,  the  kidneys, 
the  lungs,  the  liver,  and  the  pancreas 
have  all  been  tried  as  remedial  agents; 
but  it  may  be  said  that,  while  only  the 
products  of  the  first  five  have  attracted 
wide-spread  attention,  those  of  the  spleen 
and  ovaries  alone  seem  to  present  suffi- 
cient value  over  other  means  at  our  dis- 
posal to  still  merit  the  confidence  of  the 
profession. 

The  preparations  of  the  first  five  or- 
gans mentioned  in  the  list  will  be  re- 
viewed in  this  article.  The  literature  of 
the  others  is  so  scanty  that  no  adequate 
idea  could  be  conveyed  of  their  actual 
worth. 

Strength  of  organic  extracts  may  be 
tested  by  adding  to  them  Biondi's  stain- 
ing-fluid.  If  nuclein  is  present  in  large 
amount  and  the  extracts  therefore  are 
of  good  quality,  they  will  turn  a  distinct 
green.  Posner  (Berliner  klin.  Woch., 
Mar.  14,  '98). 


Splenic  Extract. 

The  use  of  spleen  was  suggested  mainly 
by  the  fact  that  enlargement  of  that 
organ  occurs  in  some  cases  of  cretinism 
and  myxosdema  and  after  removal  of  the 
thyroid  gland.  This  was  further  sub- 
stantiated by  the  experiments  of  Oliver 
and  Schiifer,  who  obtained  a  fall  of  arte- 
rial pressure  followed  by  a  gradual,  but 
steady,  rise,  by  means  of  intravenous  in- 
jections of  splenic  extract,  thus  demon- 
strating that  it  was  not  inert.  Kriiger 
found  that  it  increased  the  excretion  of 
uric  acid  and  of  the  xanthin  bases. 

Effect  of  spleen  substance  administered 
to  a  number  of  patients  in  the  Lanark 
County  Asylum,  Hartwood,  investigated 
for  a  period  of  two  years.  It  Avas  found 
to  aid  digestion  and  nutrition,  to  increase 
the  cutaneous  circulation,  to  stimulate 
the  glandular  activity  of  the  skin,  and  in 
some  cases  to  produce  a  favorable  change 
in  the  mental  condition.  A.  C.  Clark 
(Edinburgh  Med.   Jour.,   Feb.,   '98). 

Results  of  investigation  of  therapeutic 
value  of  spleen  extract.  Treatment  was 
begun  with  three  capsules  of  desiccated 
spleen  representing  100  grains  each  of 
fresh  spleen;  this  was  increased  to  6  cap- 
sules a  week  later.  Capsules  of  liquid 
extract,  each  containing  20  grains  of 
fresh  spleen,  were  tried  some  weeks  later, 
and  W'ith  more  distinct  benefit.  Conclu- 
sions are:  — 

1.  That  the  most  general  result  of  this 
treatment  is  physical  improvement. 

2.  That  its  action  on  the  mental  state 
is  undoubtedly  evident  in  a  fair  propor- 
tion of  cases,  especially  of  adolescents, 
sometimes  direct,  at  other  times  owing 
to  improved  physical  conditions. 

3.  That  it  materially  assists  in  render- 
ing thyroid  treatment  efficacious,  the  pa- 
tient, after  a  course  of  spleen  treatment, 
being  more  susceptible  to  the  action  of 
thyroid. 

4.  That  where  it  fails  there  may  be  a 
defect  in  the  preparation  of  the  extract. 
Vile  have  found  that  capsules  of  the 
liquid  extract  are  best.  They  have  been 
made  for  us  by  Duncan,  Flockhart  &  Co. 
The  desiccated  spleen,  which  is  usually 


404 


ANIMAL  EXTRACTS.     SPLENIC  EXTRACT. 


employed    for   tablets,   must   necessarily 
lose  some  of  its  active  properties. 

5.  It  is  best  given  at  least  half  an  hour 
before  meals.  Charles  A.  Bois  and  Neil 
T.  Kerr  (Brit.  Med.  Jour.,  Sept.  10,  '98). 

Administration.  —  Two  practical  dif- 
ficulties ar«  met  with  in  administering 
splenic  extract:  it  produces  gastric  pain 
and  derangement  of  the  digestion  when 
given  by  mouth,  and  great  local  irritation 
and  even  abscesses  when  administered 
hypodermically,  although,  of  course,  this 
does  not  always  follow.  A  splenic  ex- 
tract employed  by  Cohnstein  is  known 
by  the  trade-name  of  "eurythrol."  It  is 
a  watery  extract  to  which  salt  has  been 
added,  partly  to  preserve  it  and  partly 
to  give  it  a  better  flavor.  It  is  described 
as  resembling  Liebig's  beef-extract.  The 
amount  to  be  given  daily  is  from  1  to  2 
teaspoonfuls,  dissolved  in  hot  water.  It 
does  not  seem  to  occasion  distress. 

Exophthalmic  Goitre. — H.  C.  Wood 
observed  three  cases  in  which  spleen  ex- 
tract produced  very  satisfactory  results. 
One  was  cured  and  the  other  two  were 
greatly  improved.  The  advisability  of 
trying  this  remedy  is  thus  greatly  em- 
phasized. 

Case  of  severe  chronic  exophthalmic 
goitre  treated  some  years  ago,  in  which 
an  acute  splenitis  developed  in  a  manner 
which  was  altogether  inexplicable;  no 
cause  for  the  attack  could  be  made  out. 
Deep  in  the  parenchyma  of  the  organ 
there  was  formed  an  abscess  whose  open- 
ing and  discharge  were,  after  many 
months  of  severe  sepsis  and  desperate 
illness,  followed  by  return  to  health.  In 
the  second  or  third  week  of  the  splenitis 
the  enlarged  thyroid  began  to  diminish, 
and  in  a  short  time  regained  the  normal 
size.  The  result  was  a  permanent  cure 
of  the  exophthalmic  goitre,  no  symptoms 
of  the  disease  returning. 

In  a  private  case  the  disease  was  of 
six  years'  duration;  the  exophthalmos 
was  very  pronounced;  the  action  of  the 
heart  extremely  rapid  and  irregular: 
about     180.      The    enlargement    of    the 


thyroid  was  very  great.    The  breathless- 
ness  \Nas  marked^  and  the  general  nei-v- 
ous  erethism  such  that  the  patient  was 
on  the  verge  of  insanity.    A  teaspoonful 
of  the  glycerin  extract  of  spleen  produced 
at  once  violent  gastric  distress,  with  local 
pain,  lasting  for  some  hours,  and  com- 
plete   disgust    for    food.      Other    doses 
gave  similar  results.     Following  this,  10 
minims  were  injected  twice  a  day  hypo- 
dermically into  diiferent  portions  of  the 
body;     they   produced   much   local   pain 
and  hardening  Of  tissue,  but  no  abscess. 
This  was  kept  up  for  si.x  months,  when 
10  drops  of  the  spleen  extract  with  10 
drops  of  digitalis  were  administered  three 
times  a   day.     The   improvement  began 
not  a  great  while  after  the  commence- 
ment,  and  gradually  increased.     Before 
the  treatment  there  was  extreme  breath- 
lessness;    now  she  walks  comfortably  for 
a  long   distance.     H.    C.   Wood    (Amer. 
Jour.  Med.  Sciences,  May,  '97). 
Blood  Disorders.  —  The  physiolog- 
ical  functions   of   the   spleen   promptly 
suggested  the  use  of  spleen  extract  in 
diseases  of  the  blood,  and  encouraging 
results  were  obtained  by  Danilewski  and 
Cohnstein.     The  former  had  found  that 
the  use  of  a  watery  extract  of  the  ox's 
spleen,  whether  given  by  the  mouth  or 
subcutaneously,  gave  rise  to  a  notable 
increase  in  the  number  of  the  red  blood- 
corpuscles  in  dogs  and  rabbits. 

Case  of  leukaemia  treated  by  injections 
of  splenic  extract.  There  was  very  little 
pain,  but  copious  sweating  and  fear,  with 
which  dyspnoea  was  sometimes  associ- 
ated. The  effect  on  the  blood  was  a 
decided  increase  of  the  number  of  leuco- 
cytes immediately  after  the  injection, 
followed  later  by  an  increase,  not  suffi- 
cient, however,  to  restore  the  number  to 
that  previously  present.  This  result  is 
not  interpreted  as  an  evidence  of  real 
improvement  in  the  disease,  but  rather 
as  an  apparent  change  due  to  retention 
of  the  leucocytes  in  the  capillaries  of 
the  lungs.  Paul  Jacob  (Deutsche  med. 
Woch.,  Aug.  9,  '94). 

Statistics  of  twenty-three  cases  in 
which  a  watery  extract  (eurythrol)  was 
employed.     In  one  case  the  disease  was 


ANIMAL  EXTKACTS.     OVAMAN  EXTRACT. 


405 


leukaemia;  the  others  were  examples  of 
antemia  or  chlorosis.  In  the  case  of 
leukfemia  there  was  only  a  transitory 
efl'ect  observed,  not  really  therapeutical. 
On  the  other  hand,  in  the  majority  of 
the  cases  of  antemia  and  chlorosis  the 
action  of  the  extract  was  very  striking. 
The  first  signs  of  improvement  were  seen 
in  the  subjective  symptoms  of  debility, 
loss  of  appetite,  constipation,  headache, 
and  dysmenorrhoea.  Objectively,  the 
pallor  disappeared,  and  often  there  was 
an  increase  of  the  hEemoglobin  or  of  the 
number  of  the  red  blood-corpuscles.  In 
many  cases  the  patients  gained  flesh 
notably.  In  many  others  there  were  no 
objective  signs  of  improvement.  In  no 
instance  was  any  unpleasant  effect  ob- 
served. W.  Cohnstein  (Allgem.  med. 
Central-Zeit.,  No.  43,  '96). 

Extract  of  the  spleen,  by  producing  a 
decided  leucocytosis,  has  a  most  gratify- 
ing effect  upon  the  course  of  typhoid 
fever.  In  doses  of  5  grains,  three  times  a 
daj',  it  rapidly  and  steadily  reduces  the 
temperature,  ameliorates  all  the  symp- 
toms, and  quickly  restores  the  patient 
to  the  normal  condition.  To  obtain  the 
best  efi'ects  from  this  remedy,  however, 
the  percentage  of  haemoglobin  and  the 
number  of  red  coi-puscles  muse  be  kept 
up  to  normal.  Carpenter  (Med.  Record, 
Feb.  17,  1900). 
Ovarian  Extract. 

Four  well-known  facts  are  given  by 
Muret  as  fundamental  reasons  for  the 
use  of  ovarian  extract  as  a  remedy,- — 
namely,  that  (1)  without  ovaries  there 
is  no  uterine  development  or  menstrua- 
tion; (2)  ablation  of  ovaries  in  young 
children  causes  them  to  grow  up  with- 
out any  feminine  attributes:  (3)  after 
puberty  loss  of  ovaries  entails  cessation 
of  menstruation  and  atrophy  of  genital 
organs;  (4)  osteomalacia  is  cured  by 
oophorectomy, — all  generally  explained 
by  some  indefinite  action  of  the  nervous 
system.  But  the  active  principle  giving 
rise  to  these  effects  is  not  defined. 

The  following  statements  may  be  for- 
mulated in  regard  to  the  use  of  ovarian 
extract: — 


1.  The  ovaries,  in  common  with  otlier 
glandular  organs  in  the  body,  exert  an 
occult,  but  very  positive,  influence  upon 
the  general  organism. 

2.  When  this  influence  is  removed, 
either  by  the  natural  atrophy  of  the 
glands  at  the  climacteric,  by  destruction 
of  the  ovarian  stroma  from  pathological 
processes,  or  by  extirpation  of  the  organs, 
there  results  a  series  of  distressing  phe- 
nomena, including  hot  and  cold  spells, 
nervous  and  mental  manifestations,  and 
neuralgic  attacks. 

3.  The  administration  of  ovarian  sub- 
stance or  of  the  extract  of  ovarian  tis- 
sue is  promptly  and  very  generally  fol- 
lowed by  a  marked  amelioration  of  these 
symptoms. 

4.  The  average  dose  required  varies 
from  2  to  5  grains  of  the  extract  adminis- 
tered thrice  daily. 

5.  Excessive  doses  of  the  remedy  will 
be  followed  by  cardiac  and  nervous  mani- 
festations, necessitating  a  diminution  in 
the  dose  administered  or  a  complete, 
though  temporary,  change  of  treatment. 

6.  In  some  cases  there  appears  to  be 
developed  a  tolerance  to  the  remedy 
whereby  its  effects  are  diminished  in  in- 
tensity. For  this  reason  it  is  better  to 
begin  with,  small  doses  and  gradually  in- 
crease the  amount  given.  W.  A.  New- 
man Borland   (Ther.  Gaz.,  Apr.  1.5,  '99). 

Preparations  and  Dose.  —  The  ther- 
apeutic uses  of  ovarian  substance  were 
studied  by  Touvenaint.  Heifers'  ovaries 
can  be  reduced  to  powder  by  desicca- 
tion at  a  temperature  of  25°  C.  Pills 
containing  1^/^  grains  of  the  dry  powder 
can  be  used,  corresponding  to  12  grains 
of  fresh  ovary.  Three  of  these  may  be 
taken  daily  a  quarter  of  an  hour  before 
meals.  The  average  dose  of  dried  ovary 
powder  should  not  exceed  4  to  5  grains 
daily. 

Liquid  ovarian  extract  is  another  form: 
a  glycerin  extract  of  ovaries  of  young 
cows,  containing  15  grains  of  ovarian 
tissue  in  7  ^/,  minims  of  glycerin,  which 
is  injected  into  the  buttocks  daily  in 
doses  of  7  to  15  minims. 


406 


ANIMAL  EXTRACTS.     OVARIAN  EXTRACT. 


Compressed  tabloids,  containing  4  to 
5  grains  of  dried  gland,  proved  quite  as 
efficacious  as  the  injections,  when  two 
or  three  a  day  were  given,  and  were 
finally  used  in  place  of  the  injections. 
The  treatment  can  be  continued  for  a 
month  or  more  and  is  always  well  borne. 
(Muret.) 

Therapeutics.  —  In  disturbances  fol- 
lowing removal  of  the  ovaries  or  uterus, 
or  in  the  nervous  phenomena  attending 
the  menopause,  ovarian  tissue  has  given 
considerable  relief.  Lissac  first  tried 
crude  ovarian  tissue  and  ovarin  by  the 
mouth,  and  hypodermic  injections  of 
ovarian  liquid;  but  ovarin  was  found  to 
be  most  convenient,  though  it  sometimes 
caused  indigestion.  The  insomnia  from 
which  the  patients  all  suffered  was 
promptly  relieved;  cephalalgia  generally 
disappeared  and  many  psychical  symp- 
toms, mental  depression  especially,  were 
ameliorated.  In  four  of  his  cases  uterine 
hjemorrhages  ceased  under  treatment. 
The  treatment  should  be  continuous, 
however,  if  the  relief  is  to  be  maintained. 
He  mentions  sixteen  cases  treated  by 
Jayle  in  the  same  manner  in  which  the 
flushing  was  more  or  less  relieved,  but 
returned  after  cessation  of  the  treatment. 

In  exaggerated  symptoms  of  the  natu- 
ral or  induced  menopause  the  ovarian 
treatment  may  be  applied  in  two  ways: 
(1)  through  transplantation  of  ovarian 
tissue,  and  (2)  administration  by  the 
mouth.  In  case  of  induced  menopause 
through  hysterectomy  no  effect  was  ob- 
tained; but,  of  cases  presenting  severe 
sj'mptoms  during  the  natural  menopause, 
three  very  much  improved.  Chrobak 
(Centralb.  f.  Gyn.,  No.  20,  '95). 

Tablets  of  3  '/=  grains  (Merck)  of  the 
entire  ovarian  substances,  of  the  precipi- 
tate of  the  follicle-contents,  or  of  cortical 
substance  of  the  ovary  of  the  cow,  used 
in  eleven  patients,  where  either  part  or 
all  of  the  internal  genital  organs  had 
been    removed;     or    where    the    patient 


complained  of  symptoms  of  the  natural 
menopause:  amenorrhoea,  the  result  of 
atrophy  of  the  genitalia,  etc.  The  re- 
sults were,  as  a  rule,  very  encouraging, 
the  symptoms  being  very  much  relieved. 
Mond  (Mtinchener  med.  Woch.,  No.  14, 
'96). 

Ovarian  substance  used  in  patients 
who  had  reached  the  climacteric  age, 
who  complained  principally  of  sensations 
of  fullness  in  the  head,  occurring  many 
times  during  the  day,  pains  in  the  back 
and  legs,  etc.  The  dose  varied  from  15 
to  22  grains,  administered  in  tablets  con- 
taining each  7  Vi  grains  of  the  ovaries 
of  sows  or  cows.  The  sensations  of  full- 
ness in  the  head  had  practically  disap- 
peared in  two  Aveeks.  To  avoid  the  in- 
fluence of  suggestion  tablets  containing 
none  of  the  substance  were  given  from 
time  to  time,  but  the  symptoms  immedi- 
atel}'  reappeared  and  the  patients  felt 
worse.  The  effect  lasted  only  while  the 
ovarian  substance  was  being  taken.  Lan- 
dau and  Mainzer  (Lancet,  July  4,  '96). 

Ovarian  extract  tried  in  21  cases,  9 
nervous  disorder  due  to  menopause  and 
of  usual  vasomotor  origin,  insomnia, 
lumbar  pain,  visceral  troubles,  flatulence, 
anorexia,  etc.  All  cured  or  much  im- 
proved. Three  cases  of  climacteric  irreg- 
ularity of  menstruation:  2  were  cured 
and  1  improved.  Muret  (Rev.  Med.  de 
la  Suisse  Rom.,  July  20,  '96). 

Ovarian  extract  appears  to  be  par- 
ticularly indicated  in  amenorrhea  and 
ehloransemia,  in  which  the  results  are 
excellent.  It  is  very  useful  in  all  cases 
of  artificial  menopause  due  to  removal 
of  the  genital  apparatus.  It  can  also 
be  tried  with  advantage  for  the  removal 
of  symptoms  due  to  natural  menopause. 
Touvenaint   (M6d.  Mod.,  Oct.  17,  '96). 

Results  obtained  from  the  use  of  ovary- 
juice  in  various  diseases  of  women, 
especially  those  peculiar  to  the  meno- 
pause. In  51  cases,  34  of  which  were 
personal,  the  results  warrant  the  follow- 
ing conclusions:  I.  The  troublesome 
symptoms  of  the  natural  menopause  dis- 
appeared or  were  greatly  diminished  by 
the  use  of  the  ovarian  extract  without 
any  other  medication.  2.  Similar  effects 
were  produced  by  the  administration  of 


ANIMAL  EXTRACTS.     BONE-MARROW. 


407 


that  substance  in  the  relief  of  symptoms 
— for  instance,  irritability  of  the  blad- 
der—  that  follow  surgical  operations 
which  have  for  their  result  the  suppres- 
sion of  the  menstrual  flow.  3.  Rapid 
improvement  is  constantlj'  seen  in  chlo- 
rosis and  dysmenorrhoea.  4.  The  influ- 
ence of  extract  of  ovary  on  the  psychical 
disturbances  which  accompany  or  are 
dependent  on  genital  lesions  are  unde- 
niable. 5.  Rapid  and  permanent  im- 
provement in  the  general  state.  6.  Cli- 
macteric metrorrhagia  without  neoplastic 
lesions  yield  rapidly  to  the  administra- 
tion of  the  remedy.  7.  Its  therapeutic 
action  on  the  nervous  system  is  manifest 
from  the  first  day  of  its  administration. 
Author  states  that  he  will  shortly  pub- 
lish the  results  of  laboratory  researches 
as  to  the  chemical  constitution  of  the 
substance  which  he  prescribes.  C.  Jacobs 
(La  Policlinique,  Dee.  1,  '96). 

Ovarian  extracts  act  directly  for  the 
relief  of  the  distui'banees  attending  the 
menopause,  either  natural  or  artificial. 
Its  use  is  also  valuable  in  amenorrhcea, 
dysmenorrhoea,  and  in  anaemia  of  ovarian 
'origin.  Good  results  have  also  been 
noted  in  some  eases  of  simple  oophoritis. 
Jayle  (Revue  de  Gynec.  et  de  Chir.,  No. 
4,  '98). 

Oophorin  preparations  given  to  women 
suffering  from  acne  rosacea  and  cutane- 
ous disorders  at  the  menopause,  with 
satisfactory  results.  E.  Saalfeld  (Ber- 
liner klin.  Woch.,  No.  1.3,  '98). 

Extract  of  corpora  lutea,  to  which  the 
value  of  ovarian  extract  is  due,  adminis- 
tered to  patients  suffering  with  the  sub- 
jective phenomena  commonly  following 
the  menopause,  thought  to  be  due  to 
ovarian  insufficiency.  In  two  eases  in 
which  this  substance  was  used,  the 
same  results  as  those  obtained  from  the 
ovarian  extract  were  noted.  A.  Lebreton 
(Lancet,  July  1.5,  '99). 

The  nervous  disorders  following  re- 
moval of  the  ovaries  or  uterus  were  also 
found  to  be  relieved  by  Landau  and 
Mainzer,  but  only  temporarily. 

Knauer  has  shown  that  in  rabbits  the 
ovaries  can  be  removed  and  then  trans- 
planted in  other  than  their  normal  posi- 


tion. They  can  be  attached  to  the  peri- 
toneum as  well  as  implanted  between 
muscle-fibres.  Thus  implanted,  the 
ovary  is  nourished  and  continues  its 
function.  Might  this  not  be  repeated 
in  the  human  subject  to  antagonize  the 
symptoms  following  oophorectomy  or 
castration  for  hypertrophied  prostate? 

Case  in  which  bilateral  oophorectomy 
was  followed  by  flashes  of  heat,  profuse 
sweating,  headache,  and  marked  sensa- 
tions of  pressure  in  the  occipital  region 
preceding  and  during  the  early  part  of 
the  menstrual  period.  Three-fourths  to 
5  drachms  of  ovarian  substance  admin- 
istered twice  a  day  caused  the  attacks  of 
flashes  of  heat  and  sweating  to  become 
less  frequent  and  severe.  This  was  fol- 
lowed by  general  improvement.  Stachow 
(Monat.  f.  Geburtschulfe  u.  Gyn.,  B.  4, 
H.  1). 
In  disorders  of  any  kind  resulting 
from  uterine  affections,  it  seems  to  merit 
further  trial. 

Four  cases  of  chlorosis  treated  for 
fourteen  days  with  rest  in  bed  alone, 
then  a  second  period  of  fourteen  days 
with  ovarian  extract.  A  relatively  larger 
increase  of  hsemoglobin  in  the  second 
series,  and  in  three  of  these  a  larger  in- 
crease in  weight.  The  menses  appeared 
in  two  after  an  absence  of  some  months. 
Muret  (Rev.  Med.  de  la  Suisse  Eom., 
July  20,  '96). 

Ovarian  extract  is  harmful  to  chlo- 
roties  because  the  influence  of  the  ovary 
upon  the  organism  is  of  a  chemical 
nature.  The  only  form  of  opotherapy 
which  offers  any  prospect  of  success  in 
chlorosis  is  the  medullary.  U.  Arcangell 
(La  Riforma  Mediea,  No.  91,  '99). 

Bone-inarrow. 

On  the  assumption  that  the  red  blood- 
corpuscles  were  produced  mainly  from 
the  red  bone-marrow,  J.  Dixon  Mann, 
of  Manchester,  utilized  an  extract  of  this 
substance  in  anaemia  and  other  condi- 
tions dependent  upon  a  depraved  condi- 
tion of  the  blood.  The  cases  have  been 
numerous  in  which  the  results  have  ap- 


408 


ANIMAL  EXTRACTS.    BONE-MARROW. 


parently  supported  Dixon  Mann's  hy- 
pothesis, great  and  rapid  proliferation  of 
the  red  corpuscles  having  been  noted. 

Case  of  pernicious  anaemia  in  wliieh 
bone-marrow  was  employed  in  consider- 
able success.  HEemoeytes,  1,860,000  to 
1,460,000  per  cubic  millimetre;  hsemo- 
globin,  28  to  30  per  cent.  Three  ounces 
of  uncooked  bone-marrow  from  the  ox 
given  by  the  mouth  daily.  After  twenty- 
seven  days  the  hsemocytes  numbered 
3,900,000  per  cubic  millimetre  and  the 
htemoglobin  amounted  to  78  per  cent. 
Eraser  (Brit.  Med.  Jour.,  No.  1744,  '94). 

The  tissue-forming  power  of  young 
animals  being  taken  as  a  criterion,  the 
marrow  obtained  from  them  was  thought 
to  be  preferable  to  that  of  older  animals. 
The  best  results  were  obtained  from  the 
'  marrow  contained  in  the  ribs  of  a  young 
animal.  The  coarse  marrow  from  the 
long  bones  contains  a  great  deal  of  fat, 
which  does  not  contain  the  specific 
virtues  to  the  same  extent  as  the  finer 
medullary  substance. 

Preparation.  —  The  method  of  prep- 
aration advocated  by  the  majority  of 
writers  is  that  recommended  by  Dan- 
forth,  of  Chicago.  The  anterior  extrem- 
ities of  calves'  ribs  are  comminuted  so 
as  to  expose  the  cancellated  tissue,  and 
the  fragments  are  placed  in  a  jar  and 
covered  with  glycerin,  to  the  influence 
of  which  they  are  exposed  for  three  or 
four  days,  being  occasionally  agitated. 
At  the  end  of  this  time  the  liquid  is 
strained,  and  the  resulting  fluid  presents 
a  reddish,  syrupy  appearance,  without 
pronounced  odor,  and  with  the  taste  of 
glycerin.  At  flrst  a  teaspoonful  of  this 
extract  is  administered  thrice  daily. 

The  marrow  may  also  be  administered 
raw,  on  bread;  but  this  method  is 
usually  repulsive  to  the  patient. 

Physiological  Action.  —  An  indirect 
influence  as  to  the  action  of  bone-marrow 
may  be  obtained  from  recently-made  ex- 


periments by  Trambusti,  which  have 
shown  that  bone-marrow  reacts  in  the 
course  of  an  infective  diphtheritic  proc- 
ess in  rabbits  with  great  functional  activ- 
ity of  the  cellular  elements  of  which  it  is 
composed.  This  energetic  functional  ac- 
tivity of  the  cellular  elements  tends  more 
toward  the  function  of  secretion  than 
to  that  of  reproduction.  The  increased 
function  of  secretion  shows  itself  micro- 
scopically both  by  a  greater  quantity  of 
granulations  in  the  interior  of  the  cell- 
plasma,  and  by  a  greater  quantity  of 
free  gramdations.  The  great  functional 
activity  of  the  cellular  elements  is  dimin- 
ished, with  the  progress  of  the  infection, 
by  the  accumulation  of  a  greater  quan- 
tity of  toxic  material  within  the  organ- 
ism. Although  this  material  in  small 
dose  stimulates  the  above-mentioned 
energy,  yet  it  here  acts  as  a  paralyzant 
and  in  producing  necrosis.  The  results 
which  he  has  obtained  from  the  use  of 
bone-marrow  justify  the  belief  that  the 
leucocytes  produce  a  substance  which  is 
bactericidal  and  antitoxic.  Its  effects 
have  been  ascribed  in  the  presence  of 
iron. 

Whether  or  not  it  is  anything  more 
than  an  assimilable  preparation  of  iron 
is  not  conclusively  proved.  Bone-mar- 
row, especially  red  marrow,  is  certainly  a 
readily  assimilated,  organic  compound  of 
iron,  and  is  a  valuable  addition  to  the 
resources  of  the  physician  in  cases  of 
ordinary  chlorosis  and  anaemia  and  in 
some  cases  of  blood  impoverishment  of 
a  more  intractable  kind.  W.  E.  Quine 
(Boston  Med.  and  Surg.  Jour.,  Aug.  6, 
'96). 

Any  action  bone-marrow  may  have 
must  be  due  to  some  ingredient  which 
stimulates  blood-formation,  and  not  to 
iron,  or  to  any  other  constituent  which 
might  be  directly  used  to  build  up  red 
blood-corpuscles.  Stengel  (Ther.  Gaz., 
'96). 
Therapeutics. — Not  much  can  be  said 
in  favor  of  bone-marrow  as  a  therapeu- 


ANIMAL  EXTRACTS.     BONE-MARROW. 


409 


tic  agent.  In  pernicious  anaemia  it  in 
DO  way  approaches  arsenic  in  value;  in 
anaemia  indications  would  seem  to  show 
that  it  is  not  as  reliable  as  iron.  In  leu- 
cocythfemia,  leukeemia,  and  Hodgkin's 
disease  it  seems  worthy  of  more  extended 
trial. 

Peenicious  Anjjmia. — It  is  very 
doubtful  whether  bone-marrow  can  in 
any  way  be  compared  to  arsenic  as  a 
remedial  agent  in  pernicious  ansmia. 
The  belief  that  the  active  agent  of  mar- 
row is  iron  would  sustain  this  view,  iron 
being  as  useless  in  true  pernicious  ane- 
mia as  it  is  useful  in  the  benign  form. 
There  is  ground  for  the  suspicion  that 
an  erroneous  diagnosis  led  to  some  of 
the  favorable  reports  published.  These 
are  not  included  in  this  review. 

Again,  in  the  majority  of  the  cases  of 
pernicious  anaemia  treated  with  bone- 
marrow  hitherto  reported,  their  value  as 
therapeutic  records  is  much  diminished 
by  the  fact  that  other  drugs  were  often 
given  in  addition,  and  also  that  in  no 
case  has  the  further  history  and  ultimate 
fate  of  the  patient  been  recorded.  It 
is  well  known  that  such  cases  often  im- 
prove for  a  time  imder  various  forms  of 
treatment,  but  they  tend  always  to  re- 
lapse, and  ultimately  to  die. 

Case  of  pernicious  anaemia  in  a  man, 
aged  60,  treated  with  iron,  arsenic,  and 
salol,  who  made  no  progress  until  3 
ounces  of  ox-marrow  were  given  in  ad- 
dition. Complete  recovery  followed. 
Eraser  (Brit.  Med.  .Jour,,  vol.  i,  p.  1172, 
'94). 

Bone-marrow  given  in  one  case  of  per- 
nicious ansemia,  without  benefit;  in  a 
second,  however,  occurring  in  a  man  aged 
43,  who  had  become  worse  under  arsenic 
and  to  whom  3  ounces  of  fresh  marrow 
were  then  given  daily,  the  results  were 
remarkable.  In  two  months  the  blood- 
condition  had  returned  to  the  normal  in 
every  respect.  Barr  (Brit.  Med.  Jour., 
■      vol.  A,  p.  358,  '95). 


Three  cases  of  pernicious  anaemia  in 
which  the  red  marrow  did  not  have  the 
least  effect.  In  one  of  the  cases  rapid 
improvement  was  noted  as  soon  as  the 
patient  was  placed  on  arsenic.  Bone- 
marrow  should  not  be  .given  unless 
arsenic  has  failed.  G.  B.  Hunt  (Lancet, 
Feb.,  '96) . 

Case  in  which  marked  improvement 
was  brought  about  by  bone-marrow  and 
in  which  benefit  had  persisted  up  to  the 
date  of  the  report.  Janeway  (Ther.  Gaz., 
May  16,  '96). 

Two  cases  of  pernicious  ansemia  treated 
with  bone-marrow.  The  first,  a  man 
aged  39,  had  various  ups  and  downs,  but 
ultimately  succumbed.  The  second  case 
occurred  in  a  woman  aged  60;  but  under 
similar  treatment  she  also  progressively 
sank.     Stengel   (Ther.  Gaz.,  '96). 

The  most  that  can  be  said  for  bone- 
marrow  in  pernicious  ansemia  is  that  it 
should  be  tried  where  arsenic  fails. 

Anemia  and  Chloeosis.  —  In  severe 
anaemia,  whether  primary  or  secondary, 
bone-marrow  has  given  better  results 
than  in  pernicious  anaemia.  Here  it 
would  find  a  logical  application,  espe- 
cially if,  as  thought  by  Quine,  it  repre- 
sents an  assimilable  preparation  of  iron. 
The  marked  increase  of  haemoglobin  and 
the  general  improvement  noted,  espe- 
cially in  Mann's  cases,  would  seem  to 
warrant  further  trial  of  the  remedy. 

Trial  in  two  cases  of  ansemia  and  two 
of  chlorosis;  doubtful  whether  the  bone- 
marrow  treatment  is  superior  to  iron. 
J.  S.  Billings,  Jr.  (Johns  Hopkins  Hosp. 
Bull.,  vol.  V,  No.  43). 

Administration  of  the  medullary  glye- 
eride  has  shown  better  results  than  that 
of  iron  or  arsenic.  Danforth  (Amer. 
Med.-Surg.  Bull.,  May  16,  '96). 

Twenty-two  insane  male  cases  of 
ansemia  treated  with  bone-marrow.  The 
average  increase  in  red  corpuscles  was 
1,361,489.  The  percentage  of  hsemoglobin 
increased  on  an  average  of  12.5  per  cent. 
The  leucocytes,  which  in  nearly  all  were 
abnormal  at  first,  decreased  in  number 
at  the  end  of  the  month.  The  whole 
general  appearance  in  the  majority  of  the 


410 


ANIMAL  EXTRACTS.    BONE-MAREOW. 


cases  improved.  Appetite  was  better  and 
the  action  of  the  bowels  more  regular. 
Mentally,  one  case  began  to  improve  at 
once  and  soon  went  home  recovered. 
Three  were  regarded  as  much  improved 
and  four  others  were  brighter  and  had 
lost  a  great  deal  of  the  apathy  they 
formerly  had.  In  the  remaining  four- 
teen the  only  improvement  noticed  was 
in  their  physical  condition.  Best  results 
obtained  with  an  extract  made  at  the 
hospital  by  finely-chopped  ribs  of  sheep 
and  adding  glycerin  in  the  proportion  of 
one  pound  to  twelve  ribs.  This  was  per- 
mitted to  macerate  four  days.  It  was 
then  strained  through  gauze  and  was 
ready  for  use.  W.  0.  Mann  (Amer.  Jour, 
of  Insanity,  Jan.,  '97). 

Ten  cases  of  ansemia  and  chlorosis 
treated  by  a  preparation  of  nucleo- 
albumin  and  bone-marrow,  shown  in  the 
table.  D.  D.  Klots  (N!  Y.  Med.  Jour., 
Oct.  30,  '97). 


of  marrow;  it  is  not  precipitated  by 
boiling;  it  does  not  contain  iron,  and 
may  possibly  be  a  deuteroproteose. 
Fowler  (Scottish  Med.  and  Surg.  Jour., 
Sept.,  '99). 

Malaeial  Cachexia.  — •  In  malarial 
cachexia  bone-marrow  has  been  tried, 
but,  doubtless,  what  beneficial  influence 
may  have  been  obtained  was  due  to  the 
improvement  in  the  condition  of  the 
blood. 

Bone-marrow  successful  in  two  cases 
of  malarial  cachexia.  All  modes  of  treat- 
ment had  failed.  The  remedy  given  in 
daily  doses  of  1  V;  to  3  ounces,  either 
raw  or  in  sandwiches.  T.  K.  Alexeiew 
(Rev.  Gen.  de  Clin,  et  de  Ther.  Jour,  dea 
Praticiens,  Nov.  16,  '95). 

Four  cases  of  malarial  cachexia  treated 
with  the  spleen  and  bone-marrow  of 
cattle,  with  apparently  favorable  results. 


1 

Percentage  of 

Percentage  of 

No.  Ked 

No.  Red 

Weight  at 

Weight  at 

Disease. 

Haihioglobin 

Hsemoglobin 

Blood-cells  at 

Blood-cells  at 

Beginning 

End  of 

m 

at  Beginning 

at  End  of 

Besinning  of 

End  of  Four 

of 

Four 

6 

of  Treatment. 

Four  Weeks. 

Treatment. 

Weeks. 

Treatm't. 

Weeks. 

1 

Chlorosis 

54>^ 

74 

2,730,000 

4,210,000 

117 

124 

2 

Chlorosis 

43 

fiSK 

2,140,000 

4,020,000 

108 

115 

3 

Chlorosis 

51 

75 

2,340,000 

4,120,000 

93 

99 

4 

Chlorosis 

34 

61 

2,310,000 

3.990,000 

104 

113 

5 

Chlorosis 

44 

74 

2,360,000 

4,030,000 

117 

123 

6 

Secondary 

ansemia 

36 

71 

2,140,000 

4,430,000 

123 

131 

7 

Secondary 

ansemia 

51 

62 

2,420,000 

3,320,000 

1.33 

136^ 

8 

Secondary 

ansemia 

54 

esx 

2,430,000 

3,470,000 

111 

117 

9 

Secondary 

ansemia 

42 

63 

2,170,000 

3,940,000 

141 

149 

10 

Secorjdary 

ansemia 

68 

79 

3,620,000 

4,100,000 

122 

129 

1.  Subcutaneous  injections  of  bone- 
marrow  have  no  action  on  the  red  cor- 
puscles or  haemoglobin  of  a  healthy  ani- 
mal. 2.  When  the  red  corpuscles  and 
hsemoglobin  fall  below  their  normal 
limits,  injections  of  bone-marrow  produce 
a  decided  rise  in  both.  This  rise  is  well 
marked,  sudden,  and  of  short  duration. 
3.  Along  with  the  increase  in  the  red 
corpuscles  there  is  no  corresponding  im- 
provement in  the  form  of  the  cells.  4. 
The  active  principle  is  present  in  an 
aqueous,  but  not  in  an  alcoholic,  extract 


Gritzmann  ( Allg.  Wiener  med.-Zeit.,  June 
30,  '96). 
LEUCOCTTHiEMIA   AND   LeUE^MIA. 

Extracts  of  the  bone-marrow  and  of  the 
spleen  have  been  employed  in  the  treat- 
ment of  leucocythsemia,  but  so  far  there 
has  been  no  great  success,  and  the  reason 
of  the  failure  is  obvious  when  we  remem- 
ber that  in  leucocythsemia  the  bone-mar- 
row is  hypertrophied,  not  atrophied.  It 
is  not  probable  that  glycerin  extracts  of 


ANIMAL  EXTRACTS.     BONE-MARROW. 


411 


marrow  will  jDrove  valuable,  since  there 
is  already  too  much  marrow-activity. 
(H.  C.  Wood.) 

Excellent  results  from  the  treatment 
of  a  case  of  leukajmia,  in  a  lad  of  12, 
with  bone-marrow  taken  raw  and  spread 
on  bread.  After  a  few  days  the  method 
was  not  particularly  disagreeable.  The 
improvement  little  short  of  marvelous. 
Rigger  (London  Lancet,  Sept.  22,  '94). 

Good  effects  apparent  within  a  few 
days.  A.  MeLane  Hamilton  (N.  Y.  Med. 
Jour.,  Jan.  12,  '95). 

Case  of  splenic  myelogenous  leukaemia 
in  which  bone-marrow  did  not  prove 
curative.  Arsenic  had  also  been  used, 
but  its  physiological  effects  caused  it  to 
be  stopped.  Beneficial  effects  of  marrow 
shown,  however,  by  reduction  of  spleen 
and  blood-count.  C.  E.  Namraaek  (N.  Y. 
Med.  Rec,  Dee.  14,  '95). 

Case  of  leucocythsemia  in  which,  dur- 
ing seventeen  days'  treatment  under 
arsenic  (2  to  12  minims,  t.  i.  d.,  liq. 
potass,  arsenit.),  no  improvement  oc- 
curred. A  dessertspoonful  of  ox's  bone- 
marrow  spread  on  toast  being  given  three 
times  a  day  with  arsenic,  a  remarkable 
diminution  in  the  number  of  leucocytes 
followed,  and  continued  after  the  arsenic 
was  stopped.  At  the  end  of  eight  weeks 
the  erythrocytes  numbered  4,170,000,  the 
leucocytes  25,000  (1  to  167).  The  pa- 
tient left  the  hospital  and  subsequently 
ceased  taking  the  marrow.  At  the  end  of 
six  months  she  returned  with  the  spleen 
larger  than  ever;  the  erythrocytes  num- 
bering 3,670,000;  leucocytes,  225,000. 
Again  given  the  tabloids  of  bone-marrow 
and  began  to  improve  at  once.  Four 
weeks  later  the  patient  became  very  ill, 
breathless,  pulse  rapid,  temperature  102" 
F.,  pulmonary  congestion  and  pleurisy, 
oedema  of  face  and  upper  and  lower  ex- 
tremities. The  patient  died  a  week  later. 
At  the  autopsy  there  was  a  typical  leuco- 
cythajmic  spleen.  'V^Tiait  (Brit.  Med. 
.Jour.,  Apr.  4,  '96). 

Hodgkin's  Disease.  —  Eecent  obser- 
vations tend  to  show  that  bone-marrow 
may  become  a  valuable  remedy  in  certain 
forms  of  Hodgkin's  disease. 

Case  of  Hodgkin's  disease  at  first 
placed  on  one  fresh  sheep's  thyroid  daily. 


Tiring  of  them,  the  patient  was  placed 
upon  extract  of  bone-mairow  and  thy- 
roid. From  this  time  on  there  was  rapid 
amelioration  in  all  of  the  symptoms. 
The  cough  and  night-sweats  ceased  and 
the  glands  rapidly  diminished  in  size. 
Six  months  later  she  reported  herself  as 
feeling  quite  as  well  as  she  did  before  her 
illness.  The  enlargement  of  the  glands 
had  all  disappeared.  M.  B.  Herman 
(Memphis  Med.  Monthly,  Feb.,  '96). 

Well-marked  case  of  Hodgkin's  disease, 
erratic  temperature,  varying  from  nor- 
mal to  102.5°  F.  Patient  put  upon  the 
usual  arsenic  treatment,  beginning  with 
2  minims  thrice  daily,  and  gradually  in- 
creasing the  dose  until  she  was  taking 
7  minims  three  times  a  day  of  Fowler's 
solution,  but  in  spite  of  this  she  steadily 
and  rapidly  got  worse,  till  at  the  end  of 
five  weeks  she  was  a  perfect  skeleton, 
profoundly  ansemic,  sleepless,  and  the 
group  of  glands  affected  so  agglutinated 
that  outlines  of  single  glands  were  quite 
obliterated.  The  spleen  was  enlarged, 
temperature  was  almost  constantly  about 
100°  F.,  and  her  digestion  failed  com- 
pletely. The  case  seemed  rapidly  mov- 
ing toward  a  fatal  termination. 

Although  bone-marrow  tabloids  had 
previously  been  tried  in  a  case  of  the 
same  disease  in  an  adult  without  the 
smallest  benefit,  they  were  used  in  this 
case  beginning  with  1,  thrice  daily.  The 
vomiting  and  diarrhoea  soon  ceased  and 
the  temperature  was  normal.  This  im- 
provement steadily  continued.  The  num- 
ber of  tabloids  taken  was  gradually  in- 
creased, till  at  the  end  of  a  fortnight 
she  was  taking  6  in  the  day.  After  two 
months  she  was  apparently  in  good 
health,  although  the  submaxillary  and 
one  of  the  cervical  glands  were  still 
large.  The  tabloids  were  finally  stopped. 
A  fortnight  afterward  she  was  once  more 
somewhat  ansemie,  and  with  the  glands, 
which  had  subsided  to  normal,  ap- 
preciably enlarged;  tabloids  resumed; 
she  still  continues  to  take  3  a  day,  and 
is  now  a  plump,  healthy  child,  but  she 
still  presents  slight  enlargement  of  the 
submaxillary  and  one  cervical  gland. 
J.  D.  L.  Macalister  (Brit.  Med.  Jour., 
Nov.  13,  '97). 
Osseous  Deformities.  —  Although 


412 


ANIMAL  EXTEACTS.     ORCHITIC  EXTRACT. 


affording  but  little  information  as  to 
the  actual  value  of  marrow  in  disorders 
of  bone,  the  following  cases  are  never- 
theless suggestive: — 

Case  of  rheumatoid  arthritis  with  sym- 
metrical spindle-shaped  joints  and  ulnar 
deviation.  Under  marrow,  pain,  creak- 
ing, and  deformity  were  markedly  re- 
duced. 

Case  of  rheumatic  ankylosis  of  right 
wrist  in  a  woman  aged  43,  flexion  and 
supination  being  lost.     Improvement. 

Case  of  lateral  curvature  in  a  girl  aged 
17  '/j.  The  point  gained  was  increased 
development  of  both  sides  of  the  chest, 
but  much  more  on  the  weaker  side. 

Case  of  angular  cuiwature  in  a  girl 
aged  18.  The  curvature  itself  not  re- 
duced in  size,  but  its  irregularities  have 
become  smoother. 

Extreme    case    of    osteomalacia   in   a 
woman  aged  44.     The  patient  had  not 
walked   for  twenty  years.     After   bone- 
marrow   treatment   she    could   stand   by 
holding  to  a  chair,  and  could  get  from 
her  bed   into   a   chair   unaided.     T.   M. 
Allison    (Med.  Press  and  Circ,  Oct.   14, 
'96). 
Orehitic,  or  Testicular,  Extract. 
As  is  well  known,  the  removal  of  the 
testicles    transforms    the    physical    and 
mental  attributes  of  an  animal.     Upon 
this  is  based  the  natural  conclusion  that 
these  glands  bear  considerable  influence 
upon  general  development  and  nutrition. 
With  this  undeniable  fact  before  him, 
Brown-Sequard  conducted  investigations 
having   for   their   object   to    determine 
whether  the  product  could  not  be  util- 
ized as  a  therapeutic  agent,  and,  after  a 
series  of  experiments  upon  his  own  per- 
son, he  ascertained  that  testicular  fluid 
was   capable   of  increasing   mental   and 
physical  vigor.    As  to  the  curative  influ- 
ence on  the  various  morbid  conditions  of 
the  organism,  he  was  of  the  opinion  that, 
by  injection  under  the   skin,  it  could 
bring  about  the  cure  or  considerable  im- 
provement   of    organic    or    non-organic 
affections  of  the  most  varied  character, 


or,  at  least,  cause  their  effects  to  dis- 
appear. These  actions  of  the  liquid  were 
thought  to  be  brought  about  in  two  ways : 
the  nervous  system,  gaining  in  force, 
became  capable  of  ameliorating  the  dy- 
namic or  organic  state  of  the  diseased 
parts,  and,  by  the  entrance  into  the 
blood  of  new  material,  new  cells  or  other 
anatomical  elements  were  formed,  thus 
contributing  to  the  cure  of  the  morbid 
condition. 

Unfortunately  clinical  evidence  has 
not  sustained  the  hopes  of  the  distin- 
guished ph)rsiologist,  and  the  method 
introduced  by  him  has,  for  the  present, 
at  least,  practically  fallen  into  disuse. 

Testicular  liquid  was  thoitght  to  pos- 
sess such  antiseptic  properties  that,  if 
it  should  be  contaminated  by  pathogenic 
germs,  these  germs  would  be  rapidly 
killed  or  rendered  powerless;  but  it  was 
shown  that  the  antiseptic  properties  were 
merely  those  possessed  by  any  acid  sub- 
stance over  certain  micro-organisms. 

Instances  tending  to  show  that  the 
testicular  fluid  prepared  at  the  Coll6ge 
de  France  enjoyed  certain  antiseptic 
properties.  It  can  retard  for  a  month 
the  putrefaction  of  a  piece  of  meat  placed 
in  it.  Brown-Sequard  (Archives  de 
Phys.  Normale  et  Path.,  Oct.,  '93). 

Testicular  fluid  always  has  an  acid 
reaction,  so  that  it  is  not  surprising  that 
it  sterilized  organisms  -which  could  live 
only  in  an  alkaline  medium.  If  microbes 
which  could  adapt  themselves  to  a 
slightly-acid  medium  were  chosen,  such 
as  the  bacillus  eoli  communis,  the  results 
Avere  no  longer  the  same.  Sabrazes  and 
Riviere  (Jour,  de  M6d.  de  Bordeaux, 
Nov.  26,  Dec.  3, '93). 

Brown-Sequard's  testicular  fluid  con- 
tains two  substances  which,  when  in- 
jected, are  useful,  and  substances  which 
have  a  disturbing  action  on  the  metabo- 
lism. Hirsch  (St.  Petersburger  med. 
Woch.,  S.  51,  No.  7,  '97). 

Preparation. — D'Arsonval  and  Brown- 
Sequard      recommend      the      following 


ANIMAL  EXTRACTS.     OECHITIC  EXTRACT. 


413 


method:  Take  the  testicles  of  a  bull, 
divide  each  into  four  or  five  portions. 
Macerate  for  twenty-four  hours  in  glyc- 
erin at  86°  F.,  in  the  proportion  of  1 
quart  per  kilogramme  of  testicle.  Add 
5-per-cent.  salt-water,  ^/^  litre  to  1  kilo- 
gramme of  glycerin.  Mix  and  allow  to 
macerate  half  an  hour.  Filter  through 
Laurent  paper  No.  8,  and  sterilize  the 
filtered  liquid  either  by  carbonic  acid 
(sterilized  filter,  or  an  autoclave  with 
carbonic  acid  without  filtration  through 
porcelain)  or  by  filtration  with  alumin- 
ium without  carbonic  acid  (a  process 
inferior  to  the  others,  but  simpler  and 
within  the  reach  of  practitioners).  The 
quantity  of  liquid  from  1  kilogramme 
of  testicle  in  the  glycerin  varies  from 
600  to  500  grammes.  The  quantity  of 
glycerin  is  brought  back  by  the  addition 
of  salt-water  at  about  15°  Baume.  The 
liquid,  in  flasks  containing  30  grammes, 
well  corked  and  previously  well  washed 
in  boiling  water,  keeps  for  several  months 
without  alteration. 

This  liquid  must  be  injected  under 
the  skin,  not  pure,  but  one-half  diluted 
with  water  recently  boiled  and  cold.  If 
the  injection  be  painful,  the  liquid 
should  be  further  diluted  with  water  (10 
to  40  drops).  All  vessels  employed,  as 
well  as  the  syringe,  cannula,  skin  of  the 
patient,  and  fingers  of  operator  should 
be  carefully  washed  in  2-per-cent.  car- 
bolized  water  before  and  after  injection. 
At  least  2  grammes  of  the  diluted  fluid 
should  be  daily  injected,  and  even  5,  6, 
or  8  grammes,  diluted,  or  else  4  to  8 
grammes  should  be  injected  in  several 
places  twice  a  week,  preferably  into  the 
abdomen,  between  the  shoulders,  or  into 
the  buttocks.  The  treatment  shoiild  be 
continued  three  weeks,  and  for  some 
affections,  such  as  myelitis  and  sclerosis 
of  the  cord,  the  time  cannot  be  limited, 
but  may  be  two  or  three  months.    Water 


should  never  be  added  to  the  liquid  in 
the  flask.  The  injections  should  be  sus- 
pended if  untoward  effects  are  observed. 
The  remedy  may  also  be  given  per 
rectum,  but  diluted  with  water  to  avoid 
local  irritation. 

Another  method  of  preparing  a  steril- 
ized liquid  is  the  following:  The  tes- 
ticles are  macerated  in  glycerin  for 
twenty-four  hours,  and  then  filtered  into 
a  second  apparatus  through  Chardin 
paper,  which  has  been  sterilized  in  car- 
bon dioxide  under  a  pressure  of  fifty 
atmospheres  for  three  or  four  hours.  It 
is  not  certain  that  the  combined  action 
of  concentrated  glycerin  and  carbon 
dioxide  under  a  pressure  of  fifty  atmos- 
pheres will  result  in  perfect  sterilization; 
therefore  the  use  of  extracts  heavily 
charged  with  glycerin  is  persisted  in. 
The  new  extracts  are  more  active,  as  has 
been  shown  by  experiment.  The  liquid 
should  not  be  injected  pure,  but  diluted 
with  two  or  three  times  its  volume  of 
1-per-cent.  salt  solution,  or  carbolized 
water,  1  per  1000.  This  solution  should 
be  made  very  slowly,  so  that  an  intimate 
mixture  may  be  made.     (D'Arsonval.) 

Physiological  Action.  —  Beyond  the 
fact  that  it  is  capable  of  acting  as  a 
stimulant  of  vital  energy  and  thus,  per- 
haps, antagonize,  to  some  extent,  the  de- 
bilitating influence  of  morbid  processes, 
it  is  probable  that  suggestion  plays  the 
most  important  role  in  the  results  ob- 
tained. This,  at  least,  is  the  opinion  of 
the  great  majority  of  clinicians. 

In  the  great  majority  of  cases  the  or- 
ganic extracts  act  only  by  suggestion; 
sterilized  water  produced  exactly  the 
same  effects  as  brain-substance,  when 
injected  In  neurasthenia  and  hemiplegia. 
V.  Negel  (Bull,  de  la  Soc.  des  Med.  et 
Nat.  de  Jassy,  Nov.  1,  '92). 

If  the  injections  were  followed  by  the 
use  of  neutral  glycerin  an  improvement 
took  place.     The  same  was  the  cage  In 


414 


ANIMAL  EXTRACTS.    ORCHITIC  EXTEACT. 


patients  treated  only  by  injections  of 
diluted  glycerin  or  of  phosphate  of  soda, 
as  well  as  in  those  to  whom  the  broiled 
organs  were  administered  at  meals.  Is 
not  this  the  best  proof  that  the  eflfects 
are  due  to  suggestion?  Guelpa  (Le  Bull. 
Mgd.,  Apr.  16,  '93). 

Experiments  with  transfusion  of  nerv- 
ous extract  according  to  the  methods  of 
d'Arsonval  and  Constantin  Paul,  in  ten 
patients  in  the  asylum  at  Eeggio.  These 
patients  were  all  of  the  curable  class, 
and  in  no  case  was  there  recovery,  and 
in  only  one  any  permanent  improvement 
under  the  treatment.  The  greatest 
effects  from  its  use  are  to  be  looked  for 
in  those  cases  where  a  physical  element 
comes  in  play,  and  that  its  action  is 
mainly  through  mental  suggestion:  an 
opinion  vigorously  sustained  by  Massa- 
longo.  C.  Eossi  (Eivista  Sperimentale 
di  Freniatria,  etc.,  vol.  xix,  No.  4). 

The  method  acts  mainly  by  suggestion. 
The  cases  in  which  benefit  had  been  ob- 
tained were  rare  and  did  not  prove  the 
antidotal  virtue  of  the  medication.  Sper- 
min  is  a  vital  principle  scattered  through 
the  entire  organism.  The  introduction 
of  spermin  into  the  system  would  be  indi- 
cated when  the  elements  of  the  economj' 
contained  it  in  smaller  quantity  than 
normal.  FUrbringer  (Deutsche  nied. 
Zeit,  Mar.  15,  '94). 

[Suggestion  plays  a  considerable  role 
in  this  method,  when  the  patients  to 
whom  it  addresses  itself  are  considered. 
Its  author  is  wrong  in  e.xaggerating  its 
value.  It  has  been  said  to  cure  tabes, 
then  cholera,  then  cancer  of  the  stomach, 
not  to  mention  a  trifling  disease  like 
diabetes.  Charcot,  hoAvever,  waited  in 
vain  for  the  cure  of  a  single  case  of  true 
ataxia  in  his  service.  How  could  it  be 
otherwise  where  such  organic  lesions 
were  concerned?  That  which  is  de- 
stroyed is  lost,  and  all  the  organic 
liquids  are  of  no  avail.  Besides,  even 
the  exact  agent  of  these  liquids  is  to 
such  a  point  unknown  that,  according  to 
some,  it  is  the  phosphate  of  soda  and 
according  to  others  phosphorus.  The 
truth  is  that  injections  of  organic  liquids 
have  generally  a  tonic  eiTect,  but  here 
their  ambition  should  end.     Dujaedin- 


Beaumetz  and  Dubief,  Assoc.  Eds., 
Annual,  '94.] 

In  a  series  of  experiments  upon  the 
action  of  orchitic  extracts  registered  by 
means  of  a  specially  devised  neuro- 
muscular apparatus,  conclusion  reached 
that  capacity  for  work  is  increased  by 
the  action  of  such  extracts,  and  in  the 
fatigue  as  well  a  diminution  in  the  sub- 
jective sensations  of  weariness.  0.  Zoth 
and  F.  Pregl  (Pfliiger's  Archives,  vol. 
Ixii,  p.  355). 

The  composition  of  orchitic  extract  of 
all  animals  found  practically  identical. 
The  active  principles  consisted  chiefly  of 
two  bodies:  (1)  nucleo-albumin  and  (2) 
spermin.  The  former  was  very  toxic, 
producing  great  cardiac  inhibition  re- 
flexly  through  the  cardiac  nerve-centres. 
The  latter,  spermin,  which  was  also  pres- 
ent in  considerable  quantity  in  semen, 
produced  its  effect  principally  by  causing 
congestion  of  the  abdominal  viscera,  in- 
eluding  both  the  testes  and  ovaries.  W. 
E.  Dixon  (Lancet,  July  7,  1900). 

Therapeutics.  —  In  diseases  of  the 
nervous  system — the  stronghold  of  the 
method — the  afEection  in  which  the 
greatest  henefit  was  claimed  was  loco- 
motor ataxia.  In  a  series  of  thirty-nine 
cases,  for  instance,  thirty-one  were  re- 
ported as  either  greatly  benefited  or 
completely  cnred.  In  much  larger  series 
the  proportion  of  cures,  etc.,  remained 
about  the  same;  but,  on  the  whole,  the 
method  has  not  in  any  way  acquired  the 
confidence  of  the  profession,  owing  to 
the  contradictory  results  obtained.  In 
truth,  Brown-Seqitard  himself  did  not 
pretend  to  do  more  than  counteract  the 
symptomatic  manifestations  of  the  dis- 
order, and  this  the  remedy  certainly  did 
for  a  time  in  a  large  number  of  cases. 
In  epilepsy,  however,  it  increased  the 
severity  and  the  number  of  paroxysms. 
In  neurasthenia  what  benefit  was  ob- 
tained did  not  prove  lasting. 

Experiments  in  patients  suffering  from 
neurasthenia,  hysteria,  pulmonary  tuber- 
culosis, and  locomotor  ataxia.    Testicular 


ANIMAL  EXTRACTS.  BRAIN  AND  NERVE  EXTRACT. 


415 


juice  has  no  physiological  or  therapeutic 
action  upon  the  human  organism;  espe- 
cially is  there  no  action  on  the  dynamo- 
metrical  forces;  it  may  have  an  irri- 
tating local  action;  whatever  effects  are 
observed,  ephemeral  and  illusory,  they 
should  be  attributed  to  the  accidental 
variations  of  the  disease,  and  principally 
to  the  action  of  suggestion.  Magugliani 
(Gazzetta  Med.  di  Pavia,  May  1,  '93). 

In  certain  cases  it  is  wrong  to  at- 
tribute the  curative  effects  of  the  tes- 
ticular liquid  to  suggestion.  In  certain 
animals  the  physical  modifications  ob- 
served in  patients,  such  as  slackening  of 
the  pulse,  increase  of  muscular  power, 
etc.,  have  also  been  observed.  The  cura- 
tive results  are  due  to  a  special  substance 
that  gives  to  the  nervous  system  a  force 
which  it  lacks.  As  regards  ataxia  cured 
by  this  method,  one  must  admit  the  dis- 
appearance of  the  symptoms,  even  if  the 
lesion  be  not  cured.  Bouffe  (Le  Bull. 
M6d.,  June  4,  '93). 

As  far  as  locomotor  ataxia  is  con- 
cerned, testicular  liquid  acts  by  sugges- 
tion, and  that  this  suggestive  influence 
is  all  the  more  manifest  because,  for  the 
most  part,  ataxic  patients  are  doubly 
hysterical.  The  symptoms  which  are 
cured  in  these  ataxics  are  precisely  those 
dependent  on  hysteria.  Berillon  (Le 
Bull.  Med.,  June  4,  '93). 

Twenty-eight  cases  of  epilepsy  treated 
by  the  subcutaneous  injection  of  testic- 
ular fluid  submitted  to  the  treatment  for 
a  sufficient  length  of  time  to  form  a  fair 
test  of  its  value.  In  eight  there  was 
slight  diminution  of  the  fits.  In  the 
other  twenty  the  fits  increased.  In  none 
of  them  did  the  intellectual  state  show 
amelioration.  Bourneville  and  Paul  Cor- 
net (Le  Progres  Med.,  Dee.  9,  16,  '93). 

Failure  in  a  number  of  cases  of  ataxia, 
sclerosis,  paralysis  agitans,  etc.;  what- 
ever temporary  amelioration  occurred 
attributed  to  mental  suggestion.  G.  W. 
Wood  and  A.  T.  Whiting  (London  Lan- 
cet, Feb.  3,  '94). 

No  improvement  whatever  in  some 
cases  of  tabes  dorsalis  in  which  it  was 
tried.  Carter  (Liverpool  Medico-Chir. 
Jour.,  July,  '94). 

Orchitic  extract  used  in  a  large  num- 
ber of  cases.     All  cases  of  nervous  dis- 


ease, without  organic  lesions,  which  are 
benefited  by  bromide  of  potassium,  will 
receive  marked  benefit  from  orchitic  ex- 
tract. H.  Grey  Edwards  (Brit.  Med. 
Jour.,  June  8,  '95). 

Forty  cases,  30  males  and  10  females, 
suffering  from  locomotor  ataxia,  sclerotic 
changes  in  the  cord,  neurasthenia,  and 
the  like,  treated  with  from  20  to  30 
minims  average  doses  of  Brown-Sfiquard's 
fluid,  frequency  of  injections  being  every 
other  day.  Nausea,  vomiting,  and  diar- 
rhoea were  caused  by  an  overdose.  Im- 
provement was  noted  in  nervous  diseases 
of  a  chi'onic  nature,  and  consisted  in  a 
general  stimulation  as  well  as  an  increase 
in  the  sexual  sense.  F.  S.  Pearce  (Med. 
News,  Aug.  22,  '96). 

Spermin  has  undoubted  beneficial  effect 
where  other  medication  has  failed.  In 
the  first  case,  after  six  injections,  in- 
continence, bladder  and  rectal  pains  dis- 
appeared, and  general  tone  and  well- 
being  improved  considerably.  After 
twelve  injections  had  been  given  ptosis 
and  oculomotor  symptoms  were  cured. 
In  the  second  case,  one  of  paralysis  agi- 
tans, the  frequent  insomnia,  which  in 
this  patient  seemed  to  be  caused  by  auto- 
into.xieation  from  gastro-intestinal  dis- 
turbances, is  usually  relieved  by  a  single 
injection  of  1  cubic  centimetre  of  sper- 
min given  hypodermically.  M.  A.  H. 
Thelberg  (Med.  News,  May  26,  1900). 

Brain  and  Nerve  Extract. 

A  number  of  observers,  most  promi- 
nent among  which,  are  W.  A.  Hammond, 
of  JSTew  York;  Constantin  Paul,  of  Paris; 
and  Dana,  of  New  York,  have  employed 
extracts  of  brain-cortex  and  of  nervous 
matter  in  various  nervous  diseases. 

D'Arsonval  prepared  a  glycerin  ex- 
tract made  of  sheep's  brain  and  spinal 
cord,  one  part  of  these  being  emulsified 
with  five  parts  of  broth. 

Dose.  —  Of  d'Arsonval's  glycerin  ex- 
tract 30  to  40  minims  may  be  injected 
either  into  the  abdominal  wall  or  into 
the  flank,  the  latter  preferably,  every 
day  or  every  other  day. 

Physiological  Action.  —  According  to 


416 


ANIMAL  EXTRACTS. 


ANOREXIA  NERVOSA. 


Althaus,  extracts  of  brain  have  a  two- 
fold action:  they  may  be  looked  upon  as 
a  highly  specialized  pabulum  of  nervous 
matter,  in  consequence  of  their  contain- 
ing protagon,  cerebrin,  and  lecithin; 
and,  in  the  second  place,  they  appear  to 
act  as  antitoxins,  as  the  phosphorized 
bodies  split  up,  under  the  influence  of 
the  alkalinity  of  the  blood,  into  glycero- 
phosphoric  acid  and  cholin,  which  have 
the  power  of  stimulating  intracellular 
oxidation  and  the  elimination  of  leuco- 
maines. 

Brain  and  nerve  extracts  have  also 
been  credited  with  stimulating  proper- 
ties, manifesting  themselves  especially 
upon  the  heart  and  the  general  nervous 
system. 

Therapeutics.  —  Hammond  and  Con- 
stantin  Paul  recorded  a  large  number  of 
cases  of  neurasthenia  in  which  excellent 
results  were  obtained,  and  stray  reports 
occasionally    appear,    tending    to    show 
that  these  extracts  are  occasionally  used. 
Four    cases    of    neurasthenia    treated 
with    subcutaneous   injections   of   liquid 
extract   of   cerebral   matter,   46    minims 
being  injected  three  times   weekly.     In 
two    eases   marked    improvement.      Vet- 
leser  (Norsk  Mag.  for  Lsege.,  Mar.,  '95). 
Brain  emulsion  in  traumatic  tetanus. 
Case  in  which  an  emulsion  of  the  calf's 
brain  with  a  physiological  salt  solution 
was  used,  233  grains  of  brain-aubstance 
being  injected  in  three  doses,  with  asep- 
tic  precaution.      Complete   recovery    oc- 
curred in  eleven  days,  although  abscesses 
at  the  points  of  injection  appeared.     A. 
Krokiewicz  (Wiener  klin.  Woch.,  No.  34, 
'98). 

Case  of  a  girl,  9  years  old,  in  whom 
240  grains  of  the  rabbit's  brain  were  em- 
ployed without  giving  rise  to  abscesses, 
because  the  brain  used  was  perfectly 
fresh,  calf's  brain  having  to  come  from 
a  slaughter-house.  Emulsion  was  also 
filtered  through  thick  sterilized  gauze. 
Schramm  (Przeglad  Lekarski,  No.  3,  '99). 
Effects  similar  to  those  obtained  from 
the  attenuated  virus   of  Pasteur  in   the 


treatment  of  hydrophobia  have  followed 
the  injection  of  brain  emulsions  obtained 
from   normal   animals,   while   functional 
nervous   diseases,   such   as   neurasthenia 
and  epilepsy,  have  been  favorably  influ- 
enced.    V.  BabSs    (Klin,  therap.  Woch., 
June  17  and  24,  1900). 
Babes  and  Gibier  recorded   cases  of 
epilepsy  which  appeared  to  be  greatly 
benefited,  while  Moncorvo  found  sheep's 
brain  extract  of  value  in  various  consti- 
tutional affections  of  childhood.     Dana 
even  reported  a  case  of  bulbar  paralysis 
apparently  cured  by  injections  of  gray 
matter,  and  Montagnon  mentions  a  ease 
of  chorea  also  cured  by  this  method. 

On  the  other  hand,  the  negative  results 
reported  have  been  numerous.  These, 
added  to  the  active  commercial  enter-  ■ 
prise  which  has  been  connected  with 
these  agents  from  the  start,  have  rele- 
gated them  to  the  rear,  and  it  may  be 
said  that  the  prevailing  opinion,  at  pres- 
ent at  least,  is  that  they  are  therapeutic- 
ally worthless. 

Practically  every  organ  of  the  body 
has  recently  been  made  to  contribute  an 
"extract,"  but  the  reports  are  too  few  to 
warrant  analysis  for  the  present. 

Charles  E.  de  M.  Sajous, 

Philadelphia. 

ANOREXIA  NERVOSA.  —  ISTervous 

anorexia. 

Definition.  —  Sympathetic  or  nervous 
anorexia  may  be  defined  as  a  manifesta- 
tion of  hysteria  in  which  there  is  total 
absence  of  hunger,  a  distaste  for  food, 
and  leading  to  voluntary  starvation. 

Symptoms.  —  Without  apparent  cause 
the  patient  expresses  a  repugnance  for 
food,  which  gradually  increases  until  all 
alimentation  is  persistently  refused.  In 
some  cases  the  repugnance  is  so  marked 
that  tricks  are  resorted  to  by  the  patient 
to  avoid  swallowing  any  aliment  that 
may  be  introduced  into  the  mouth  by 


ANOREXIA  NERVOSA.    ETIOLOGY.    PATHOLOGY.    DIAGNOSIS. 


417 


the  attendants.  Without  showing  any 
active  manifestation  indicative  of  a 
pathological  process,  the  sufferer  finally 
succumbs.  This  variety  of  anorexia  is 
occasionally  associated  with  melancholia. 
The  number  of  respirations  is  usually 
reduced,  and  the  temperature  may  be 
subnormal. 

Case    in    a  girl,   aged    14   years,    who 
showed  no  organic  lesions.    Respirations, 
12  to   14;    pulse,  46;    temperature,  97° 
F.      Cured     by     light     food     frequently 
administered.      The    patient    showed    a 
persistent    wish    to    be     constantly    on 
the  move,  notwithstanding  her  extreme 
weakness.     William  Gull    (London  Lan- 
cet, Mar.  31,  '88). 
In  marked  cases  the  skin  becomes  dry, 
wrinkled,  and  cold,  and  the  tongue  is 
parched  and  sooty. 

Etiology. — Hysteria  is  probably  a  fac- 
tor in  the  majority  of  cases. 

Case  in  a  young  girl  in  wliom  bromide 
of  potassium   caused  recovery.     It  was 
learned   that    in   the   boarding-house   in 
which  the  patient  lived  there  was  a  girl 
affected   with   an   hysterical   disorder   of 
the   larynx,   and  that   in    a    short   time 
another  young  girl  had  become  affected 
in    the    same    manner    as    the    patient. 
Schlesinger  (Wien.  med.  Blat.,  No.  3,  '88). 
Careful  inquiry  usually  shows  that  the 
patient  belongs  to  a  more  or  less  neurotic 
family.    The  condition  usually  occurs  in 
young  girls,  and  occasionally  in  children. 
Case  of  anorexia  nervosa  in  a  girl  7  Vi 
years  old,  Avho  exhibited  a  morbid  aver- 
sion to  food,  and  who  was  reduced  to  a 
skeleton,  with  marked  mental  troubles; 
however,   after   some   weeks   of  rational 
nursing  and  treatment  she  was  restored 
to  physical  and  mental  health.     Collins 
(London  Lancet,  Jan.  27,  '94). 
Pathology. — According  to  Sollicr,  the 
stomach  is  more  sensitive  than  is  gen- 
erally supposed,  and  its  sensitiveness  has 
a  large  influence  on  normal   digestion. 
The  organ  has  motor  and  secretory  func- 
tions, the  latter  depending  on  two  fac- 
tors:  the  condition  of  the  glandular  ele- 

1- 


ment  and  the  nervous  system.  It  is 
therefore  evident  that  variations  in  the 
nervous  system  may  afEect  the  amount 
of  secretion.  The  sensitiveness  of  the 
stomach  is  shown  in  three  ways:  by  sen- 
sation of  hunger,  by  contact  of  food,  and 
by  knowledge  of  satiety.  In  the  anorexia 
of  hysteria  he  has  often  found  an  area 
of  cutaneous  anaesthesia  over  the  region 
of  the  stomach,  which  varies  in  intensity 
with  the  degree  of  altered  sensation  in 
the  stomach  itself;  further,  it  is  present 
only  so  long  as  the  feeling  of  hunger  is 
absent,  and  disappears  when  desire  for 
food  returns.  It  cannot  be  satisfactorily 
made  out  in  the  graver  forms  of  hysteria, 
where  cutaneous  aneesthesia  is  extensive. 
If  the  mechanical  functions  are  also  in- 
volved there  may  be  gastric  atony. 

Case  of  hysterical  anorexia  in  which, 
while  there  was  no  evidence  of  visceral 
disease,  and  no  sugar  in  the  urine,  the 
breath  smelled  of  acetone,  and  the  urine 
gave  a  most  marked  reaction  of  aceto- 
acetic  acid.  There  was  vomiting,  and 
the  vomit  also  contained  acetone.  In 
the  first,  or  comparatively  fasting, 
period,  acetone^  aceto-acetic  acid,  oxy- 
butyric  acid,  and  ammonia  were  found. 
The  amount  of  urine  was  small,  and 
hence  a  considerable  excretion  of  acetone 
occurred  through  the  lungs.  With  suffi- 
cient nutrition  the  smell  of  acetone  in 
the  breath,  the  reaction  with  ferric  chlo- 
ride in  the  urine,  and  the  increased  am- 
monia excretion  disappeared.  Nebelthau 
(Centralb.  f.  inn.  Med.,  Sept.  25,  '97). 

Diagnosis.  —  Cancer. — The  fact  that 
carcinoma  of  the  stomach  may  be  simu- 
lated by  grave  forms  of  hysteria  seems 
scarcely  possible,  and  yet  cases  are  en- 
countered in  which,  after  long  observa- 
tion, the  diagnosis  is  uncertain.  Hyster- 
ical cases  have  even  been  met  with  in 
which,  with  all  the  subjective  symptoms 
of  gastric  cancer,  there  has  eventually 
appeared  an  apparently  pathognomonic 
tumor,   the   growth  being  composed   of 


418 


ANOREXIA  NERVOSA.    PROGNOSIS.    TREATMENT. 


the  patient's  own  hair  which  she  had 
swallowed. 

Gastric  Ulcer. — Severe  pain,  nausea, 
and  vomiting,  which  are  occasionally  ob- 
served in  anorexia  nervosa,  may  suggest 
gastric  ulcer,  but  the  other  symptoms — 
the  character  of  the  pain  and  the  time 
at  which  it  occurs — will  usually  serve  to 
clear  the  diagnosis. 

Diabetes.  —  This  condition  may  be 
suggested  by  the  facies  of  a  case,  but  the 
degree  of  wasting  is  far  greater  in  ano- 
rexia, and  the  urine  does  not  contain 
sugar. 


Eatal  case  of  anorexia  nervosa  in  a  girl 
aged  sixteen  years.     {Stephens.) 

Prognosis.  —  Anorexia  nervosa  but 
rarely  proves  fatal.  When  great  debility 
is  reached,  manifested  by  a  dry,  wrinkled, 
cold  skin;  a  small,  rapid  pulse;  and  a 
dry,  sooty  tongue,  the  likelihood  is  that 
death  will  ensue  unless  forcible  means 
are  utilized. 

Two  eases  ending  in  death.  The  dis- 
ease is  rarely  fatal  of  itself,  death  coming 
on  through  some  other  disease.  Tuber- 
culosis has  been  known  to  supervene  in 
these  eases.  Nothing  prepares  the  soil 
better  for  tuberculosis  than  anorexia. 
Debove   [Le  Progres  Mgd.,  Oct.  19,  '95). 

Fatal  case,  in  a  girl  of  16  years,  simu- 
lating diabetes.  Urine  normal.  Up  to 
eleven  months  before  death  the  patient 
was  a  fine  healthy-looking  girl.     After 


death  the  body  weighed  but  forty-nine 
pounds.  The  bi-ain  and  other  organs 
found  normal.  Lockhart  Stephens  (Lon- 
don Lancet,  Jan.  5,  '95). 

Treatment.  —  Isolation,  hypnotic  sug- 
gestion, hydrotherapy,  gastric  electriza- 
tion,— intra  and  extra, — gavage,  and  lav- 
age of  the  stomach  have  all  proved  useful 
in  some  cases.     But  occasionally  these- 
means  fail.     In  these  cases  Debove  in- 
sists on  the  necessity  of  compelling  the 
patient  to  eat,  by  whatever  means,  the- 
appetite  returning  as  the  case  improves. 
Anorexia   nervosa   in  a  man,  aged  25- 
years,  whose  weight  was  seventy  pounds,, 
in   which    compulsory    feeding   was   era- 
ployed.     The  patient,  who  had  been  in 
bed  five   years,   gained  fourteen   pounds- 
after  a  month's  treatment.     Drummond 
(London  Lancet,  Oct.  19,  '95). 
Hypodermic    injections    of   morphine- 
have  been  recommended,  but  the  danger 
of    producing   morphinomania    in    such 
cases  is  very  great.    This  method  should, 
therefore,  be  used  with  the  greatest  of 
care,  and  only  after  all  other  means  have 
failed. 

Three  cases  successfully  treated  in  the 
following  manner,  after  all  other  means- 
had  failed:  Morphine,  about  V^  grain, 
was  injected  at  four-hour  intervals,  until 
three  doses  had  been  given,  or  until  there 
was  paralysis  of  the  stomach-wall  (in 
two  cases  three  doses  accomplished  this- 
result) .  Each  patient  was  told  that  she 
would  become  numb,  that  her  pains- 
would  diminish,  and  that  she  would  be 
able  to  take  and  retain  the  food  that 
would  be  given  to  her  a  half-hour  after 
the  injection.  The  injection  should  be 
given  at  the  same  hour  each  day,  and' 
be  followed  in  a  half-hour  by  the  admin- 
istration of  food,  either  with  gavage  or 
without  gavage.  The  patient  should  also 
be  assured  thut  the  food  will  be  retained, 
and  that  it  will  not  give  rise  to  pain. 
After  having  used  morphine  in  the  man- 
ner indicated,  these  patients  become 
hypnotizable  and  suggestionable  in  a  few- 
days.  The  diminution  of  the  dose  of 
morphine   should  be  made  progressively- 


ANTHRAX.     DEFINITION.     SYMPTOMS. 


4:19 


as  soon  as  alimentation  and  assimilation 
have  been  sufficient  to  augment  the 
bod}'- weight.  S.  Dubois  (Le  Progres 
Med.,  Feb.  22,  '96). 

ANTHKAX.— Gr.,  di'dpu^,  a  coal. 
Definition. — A  malignant  pustule  due 
to  infection  by  the  bacillus  antliracis,  by 
which,  from  an  infected  centre,  it  may 
spread  over  the  body  or  attack  the  intes- 
tinal tract,  resulting  in  a  general  infec- 
tion. It  is  also  known  as  "wool-sorters' 
disease"  in  man  and  "splenic  fever"  in 
animals. 

Danger  luiks  particularly  in  the  manes 
of  Russian  horses;  so  notorious  is  the 
risk  that  manufacturers  refuse  to  have 
anything  to  do  with  them.  The  stuffing 
for  chairs  and  sofas  is  another  source  of 
infection.  When  the  material  has  been 
washed  it  is  usually  found  to  have  di- 
minished by  40  per  cent.  Editorial 
(Indian  Lancet,  Aug.   16,  '97). 

Death  of  five  men  in  JeflFerson  County, 
Pa.,  due  to  anthrax  derived  from  hand- 
ling infected  hides  imported  from  Asia. 
The  hides  had  been  treated  with  arsenic 
and  had  been  washed  in  a  neighboring 
creek.  The  trouble  maj'  have  been  due 
to  drinking  the-  water.  SeA'eral  cattle 
which  drank  of  the  water  suddenly  died. 
Editorial  (Med.  News,  Sept.  4,  '97). 

Seventy-two  cases  of  anthrax  met  with 
in  a  factory  near  Paris  where  skins  are 
tanned   and   wool   prepared.     Skins   and 
fleeces  coming  from  Turkey,  Russia,  Bul- 
garia, and  Argentine  are  infectious.     Of 
the   72   cases,   62   were   cured,   giving   a 
death-rate   of    14   per   100.     Among   the 
hands  employed  in  treating  skins  there 
were  57  cases  among  560,  15  among  160 
workers  engaged  in  preparing  wool  and 
tails.     Prophylactic  measures  are  of  the 
greatest    importance.      M.    le    Roy    des 
Barres   (Brit.  Med.  Jour.,  Sept.  25,  '97). 
Symptoms. — The  clinical  diagnosis  is 
not    always   easy.      The   most   frequent 
primary  lesion  is  in  the  face.    The  first 
symptom  is  a  sense  of  itching,  followed 
by  a  red  spot  resembling  a  flea-bite;    a 
small  vesicle  forms  soon  afterward,  con- 
taining a  bluish  fluid.    The  surrounding 


skin  is  somewhat  indurated  and  swelled. 
This  changes  into  a  black  spot,  which 
soon  becomes  gangrenous.  If  the  oedema 
continues  fresh  crops  of  vesicles  often 
appear,  undergoing  the  same  change,  and 
infecting  the  adjacent  lymphatic  glands. 
The  period  of  incubation  is  from  one  to 
three  days,  while  the  development  of  the 
local  symptoms  occupies  from  three  to 
nine  days.  A  line  of  demarkation  may 
then  form,  and  the  slough  separates.  No 
pus  is  present.  General  disturbance  be- 
gins only  a  day  or  two  after  the  mani- 
festation of  the  disease.  There  may  be 
no  fever,  bu.t  in  some  cases,  especially 
when  the  face  is  involved,  a  sudden  rise 
of  temperature  may  present  itself,  de- 
noting a  dangerous  condition. 

Headache,  nausea,  and  pain  in  the 
muscles  appear,  with  a  weak  and  rapid 
heart.  There  is  slight  icterus.  The 
prostration  is  great,  and  the  last  stages 
of  the  disease  finds  the  patient  almost  in 
the  algid  stage  of  cholera. 

Case  in  which  high  fever  (104.8°  F.), 
with  delirium,  feeble  pulse,  and  sweating, 
developed  on  the  fourth  day,  previous  to 
which  the  case  had  presented  the  char- 
teristics  of  ordinary  phlegmonous  cellu- 
litis. Recovery  after  excision,  cauteriza- 
tion, and  inoculation  with  cultures  of 
bacillus  pyocyaneus.  C.  E.  Nammack 
(N.  Y.  Med.  Jour.,  July  17,  '97). 

When  infection  takes  place  through 
the  alimentary  canal,  the  disease  begins 
with  debility,  depression  of  spirits,  ma- 
laise, and  probably  a  chill.  In  addition 
the  symptoms  point  to  the  intestines- 
Haemorrhages  occur  from  the  mouth  and' 
nose;  vomiting  is  followed  by  a  bloody 
diarrhoea.  The  diagnosis  is,  however,, 
extremely  difficult,  and  the  microscopical! 
examination  of  the  blood  or  an  inocula- 
tion of  an  animal  furnishes  the  only  con- 
clusive evidence. 

Difference  between  effects  of  the  local- 
ization of  the  pneumococcus  and  that  off 


420 


ANTHRAX.     ETIOLOGY. 


the  anthrax  bacillus.    In  the  former  true 
eucephalitic  phenomena  are  produced;  in 
the  latter,   only   haemorrhages.     This   is 
evidently   ascribable  to   a   difference   in 
the  metabolic  products  of  the  respective 
micro-organisms.     E.   Fraenkel    (Zeit.   f. 
Hyg.  u.  Infectionsk.,  B.  27,  H.  3,  '98). 
Etiology.  —  Anthrax  was  one  of  the 
first  diseases  traced  to  a  specific  micro- 
organism. 

Pollender  discovered  in  1849  small 
rod-shaped  bodies  in  the  blood  of  ani- 
mals suffering  from  anthrax,  but  Da- 
vaine,  in  1863,  proved  their  etiological 
significance.  Pasteur  and  Koch,  observ- 
ing that  the  bacilli  bore  spores,  culti- 
vated them  successfully  outside  of  the 
body,  and  then  produced  the  disease  by 
inoculating  animals  with  the  pure  cult- 
ures. 

The  anthrax  bacilli  are  large  rods, 
with  a  rectangular  form,  caused  by  the 
very  slight  rounding  of  the  corners. 
They  measure  5  to  20  microns  in  length 
and  are  1  to  1.25  microns  in  breadth. 
They  form  long  threads,  in  which  the 
single  bacterium  can  be  made  out.  At 
times  isolated  rods  occur.  In  this  stage 
granular  bodies  appear  in  the  protoplasm 
of  the  bacilli.  They  eventually  form 
glistening  oval  spores,  one  of  which  lies 
in  each  segment  of  the  long  thread,  giv- 
ing the  threads  an  appearance  of  a  string 
of  beads.  The  bacilli  soon  break  up,  and 
the  spores  become  free.  In  this  condi- 
tion the  spores  become  highly  resisting 
and  can  be  preserved  a  very  long  time. 
If  again  placed  under  favorable  circum- 
stances each  spore  will  germinate  into  a 
mature  cell.  Spore-formation  takes  place 
only  at  temperatures  ranging  from  18° 
to  43°  C,  37.5°  C.  being  the  most  favor- 
able temperature. 

The  anthrax  bacilli  can  rapidly  be 
stained  by  aqueous  solutions  of  aniline 
dyes,  and  also  by  Gram's  method.  The 
spores  are  best  stained  at  a  high  tem- 


perature by  means  of  Ehrlich's  aniline- 
water-fuchsin  solution  or  Ziehl's  solu- 
tion containing  carbolic  acid,  instead  of 
Ehrlich's  fuchsin  solution. 

The  virulence  of  anthrax  bacilli  can 
be  attenuated  in  various  ways,  such  as 
subjecting  them  to  a  high  or  low  tem- 
perature or  making  the  cult^^re  grow  for 
a  long  time — twenty-four  days  or  so — 
at  a  temperature  of  42°  or  43°  C.  By 
treating  them  in  some  such  manner  it 
is  possible  to  render  anthrax  bacilli  en- 
tirely innocuous  (Koch,  Loeffler).  Pas- 
teur rendered  sheep  and  cattle  immune 
against  anthrax  by  inoculating  them 
with  a  culture  which  grew  at  a  tempera- 
ture of  42°  C. 

Dogs,  pigs,  and  the  majority  of  birds 
are  immune  from  anthrax;  also  rats  and 
frogs  under  ordinary  conditions.  But 
if  a  frog  in  whose  lymph-sac  are  placed 
anthrax  bacilli  is  put  in  an  incubating 
apparatus,  he  will  quickly  die  of  anthrax. 
Birch-Hirschfeld  and  others  have  proved 
that  anthrax  bacilli  can  be  transmitted 
from  mother  to  foetus  in  utero. 

Experiments  to  determine  the  influ- 
ence of  the  serum  of  immunized  animals. 
A  sheep  was  immimized  until  it  could 
bear  the  injection  of  7  agar-agar  cult- 
ures with  but  slight  elevation  of  tem- 
perature. A  lamb  was  immunized  like- 
wise to  the  highest  degree  and  blood 
was  taken  from  the  carotid  artery  of 
both  animals  in  order  to  obtain  serum. 
With  the  serum  of  the  sheep  it  was  actu- 
ally possible  to  save  from  death  a  rabbit 
in  which  an  extremely  virulent  culture 
of  anthrax  was  injected,  either  after  or 
simultaneously  with  the  serum.  Evi- 
dent therapeutic  results  were  obtained 
with  this  serum  in  animals  that  had 
received  the  anthrax  bacilli  previous  to 
the  injection  of  serum. 

The  attenuated  form  of  anthrax  ia  not 
microscopically  different  from  the  viru- 


ANTHRAX.     PROGNOSIS. 


421 


lent  foniij  but  it  is  quicker  in  growth 
and  more  resistant.  The  more  virulent 
the  growth,  the  more  acid  it  is,  and, 
vice  versa,  the  more  alkaline  the  blood- 
serum,  the  more  difficult  it  becomes  for 
the  anthrax  bacillus  to  grow.  Behring 
(Zeit.  f.  Hygiene,  Apr.  12,  '89). 

E.xperiments  on  rabbits  and  sheep  to 
ascertain  relative  value  of  serum-thera- 
peutics and  vaccination.  Intravenous  in- 
jections of  small  doses  of  virus  are  not 
more  severe  than  subcutaneous  ones,  but 
large  quantities  are  far  more  lethal  when 
given  in  the  veins.  A  sheep  vaccinated 
is  refractory  to  a  large  dose  of  anthrax, 
but  its  serum  has  no  curative  power. 
When  immunized  to  a  very  high  degiee, 
the  curative  power  of  the  serum  may  be- 
come marked  from  tAvo  to  three  weeks 
after  inoculation,  after  which  its  activity 
diminishes.  By  intensive  inoculation  of 
sheep  a  serum  is  obtainable,  having  dis- 
tinct prophylactic  properties.  As  to  the 
curative  properties  of  the  serum,  that  ob- 
tained from  rabbits  was  not  found  strong 
enough  to  avert  death.  The  immunity 
produced  by  this  serum  is  evanescent ; 
that  resulting  from  vaccination  was,  on 
the  contrary,  lasting.  Marehoux  (An- 
nales  de  I'lnstitut  Pasteur,  Nov.,  '95). 

No  immunizing  substances  found  in 
the  blood  either  of  animals  treated  with 
Pasteur's  vaccine  or  of  those  Avho  had 
passed  through  an  attack  of  anthrax.  In 
animals  treated  for  weeks  and  months 
with  increasing  doses  of  virulent  anthrax 
cultures  so  that  an  active  immunity  is 
acquired,  such  protective  substances  are 
present  in  the  blood.  The  serum  ob- 
tained from  a  sheep  thus  treated  con- 
veyed a  certain  degree  of  immunity  when 
injected  into  rabbits.  Attempts  at  cure 
of  the  disease  in  rabbits  were  without 
effect.  In  2  out  of  7  sheep  in  which  100 
to  1.50  cubic  centimetres  normal  serum 
from  a  lamb  were  first  injected,  then 
small  quantity  of  a  virulent  anthrax 
culture,  both  animals  succumbed.  Three 
other  animals  were  given  a  single  dose 
(.50,  100,  and  200  cubic  centimetres  of 
serum)  and  later  a  virulent  anthrax 
culture.  All  these  animals  recovered. 
The  sixth  and  seventh  animals  were  also 
injected  with  smaller  virulent  cultures 
and    later   with    anthrax    serum.      Both 


recovered.  Sobernheim  (Berliner  klin. 
Woch.,  Oct.  18,  '97). 

Experiments  showing  the  comparative 
value  of  alkaline  solutions  for  the  de- 
struction of  spores.  Cultures  of  anthrax 
bacilli  rubbed  up  into  an  emulsion,  the 
bacilli  killed  by  exposure  to  a  tempera- 
ture of  158°  F.,  and  remaining  spores 
subjected  for  several  days  to  the  action 
of  solutions  containing  carbolic  acid 
alone,  and  other  solutions  containing  in 
addition  to  carbolic  acid  in  the  same 
strength  salts  such  as  sodium  chloride, 
sodium  phosphate,  and  the  like.  The 
latter  solutions  proved  much  more  active 
in  preventing  the  gi'owth  of  the  spores. 
■\\Tien  the  spores  were  first  introduced 
into  a  solution  of  sodium  chloride  and 
then  into  a  mixture  of  a  similar  solution 
and  carbolic  acid,  the  growth  of  spores 
was  much  less  active  than  when  the 
simple  salt  solution  was  not  used  first. 
The  author  believes  that  the  salts  act  by 
increasing  the  precipitation  of  proteids 
rather  than  by  changing  the  molecular 
constitution  of  the  carbolic  acid.  Romer 
(Munch,  med.  Woch.,  Mar.  8,  '98). 

The  sphalangi  of  Cyprus  is  an  insect 
resembling  an  ant  of  medium  size  whose 
sting  gives  rise  to  anthrax.  To  this  is 
ascribed  the  fact  that  anthrax  is  very 
common  in  Cyprus,  especially  among  the 
animals,  the  bacillus  being  carried  by  the 
insect  from  the  carcasses  of  such  animals 
to  human  beings.  G.  A.  Williamson 
(Brit.  Med.  Jour.,  Sept.  1,  1900). 

Case  in  which  the  source  of  infection 
was  bone-dust  which  the  patient  had 
handled.  The  patient  died  on  the  fourth 
day  after  his  initial  symptom.  The  tem- 
perature did  not  rise  above  100°  F.  The 
lesion  was  situated  on  the  breast,  where 
he  had  scratched  himself,  and  there  was 
an  entire  absence  of  pain,  severe  consti- 
tutional disturbance,  and  feeling  of  dis- 
tress. E.  F.  M.  Neave  (Lancet,  Oct.  6, 
1900). 

Prognosis. — The  prognosis  of  anthrax 
in  man,  when  infection  takes  place  ex- 
ternally, depends  mainly  upon  whether 
energetic  surgical  treatment  is  under- 
taken early  enough.  Lengyel  and  Ko- 
ranyi,  by  adopting  suitable  local  treat- 


432 


ANTHRAX.     PROPHYLAXIS.     TKEAT.MENT. 


ment,  lost  only  thirteen  out  of  one  hun- 
dred and  forty-two  cases.  Patients  with 
anthrax  resulting  from  internal  infec- 
tion (intestinal,  pulmonary)  very  rarely 
recover.     (Tillmann.) 

Of  thirteen  cases  of  anthrax  under  ob- 
servation, five  died,  in  all  of  which  the 
primary  lesion  was  on  the  lateral  aspect 
of  the  neck.  In  remaining  cases  the  in- 
itial lesion  ^\as  situated  on  the  forearm, 
cheek,  forehead,  occiput,  and  neck.  The 
serious  character  of  the  lesion  when  it  is 
situated  in  the  neck  ascribed  to  loose 
subcutaneous  cellular  tissue  allowing  ex- 
tension of  the  infection.  Radical  surgical 
treatment  apparently  aggravated  the 
progress.  Sick  (Centralb.  f.  Chir.,  Sept. 
9,  '99). 

Prophylaxis.  —  The  fact  that  French 
skins,  since  Pasteurian  inoculation  has 
been  employed  in  French  flocks,  have 
been  found  to  rarely  cause  anthrax 
speaks  in  favor  of  that  method.  Disin- 
fection, even  by  formol,  is  imcertain. 

Skins  of  French  animals  are  never  in- 
fectious, the  result,  it  is  believed,  of  an- 
thrax being  almost  stamped  out  among 
the  French  flocks  by  the  practice  of 
Pasteurian  inoculation.  Formol-vapor 
does  not  penetrate  them  sufficiently  to 
disinfect  thoroughly.  The  only  safe- 
guard against  anthrax  infection  is  the 
Pasteurian  inoculation.  M.  le  Roy  des 
Barres  (Brit.  Med.  Jour.,  Sept.  25,  '97). 
The  present  laboratory-method  of  pro- 
ducing immunity  to  anthrax  gives  rise 
to  a  very  transient  immunity,  and  in 
order  permanently  to  protect  animals 
that  are  spontaneously  exposed  it  is 
necessary  to  modify  the  method  so  as  to 
deprive  the  immunity  of  its  transitory 
character.  By  combining  passive  im- 
munization (by  means  of  serum)  with 
active  immunization  a  marked  success 
observed.  Sheep  received  mixtures  of 
anthrax  serum  and  attenuated  anthrax 
cultures,  and  were  still  immune  to  viru- 
lent cultures  one  and  one-half  months 
afterward.  A.  G.  Sobernheim  (Berliner 
klin.  AVoch.,  Mar.  27,  '99). 
Treatment.  —  In  man  the  disease  re- 
mains localized   a  lons;er  time  than   in 


animals.  Hence  it  is  possible  to  remove 
it  more  thoroughly.  Complete  extirpa- 
tion of  the  affected  part,  by  means  of 
the  Paquelin  thermocautery,  and  subse- 
quent cauterization  with  nitric  acid  are 
to  be  practiced. 

Complete  excision  of  the  pustule  is 
the  best  treatment,  except  when  vital 
structures  are  involved,  in  which  case 
injection  of  strong  solutions  of  the  most 
energetic  antiseptics  may  be  used.  H.  L. 
Burrell   (Annals  of  Surg.,  p.  621,  '93). 

According  to  Koch,  bichloride  of  mer- 
cury is  the  most  effective  poison  for  the 
anthrax  bacilli,  being  capable  of  killing 
them  when  used  as  diluted  as  1  part  to 
300,000  of  water.  Consequently  it  is  a 
good  plan  to  use,  in  and  around  the  af- 
fected part,  injections  of  1  to  100  bichlo- 
ride or  2-  to  5-per-cent.  carbolic  acid. 
General  treatment  has  been  very  unsatis- 
factory, although  Russian  authors  have 
met  with  success  by  the  energetic  use  of 
carbolic  acid  locally  and  internally. 

Theoretical  considerations  should  never 
deter  one  from  operating,  not  only  during 
the  early  stages,  but  at  whatever  period 
of  the  disease  the  cases  present  them- 
selves. There  are  a  number  of  instances 
where  success  has  followed  excision  even 
in  the  later  stages.  It  seems  that  we 
have  in  the  pustule  a  manufactory  which 
supplies  bacilli,  in  unlimited  quantities, 
and,  when  this  is  removed,  the  phago- 
cytes are  well  able  to  cope  successfully 
with  the  organisms  which  have  escaped 
in  the  blood-stream.  Lowe  (London 
Lancet,  Jan    23,  '92). 

Case  of  anthrax  of  the  nose  in  a  tanner 
successfully  treated  with  injections  of 
carbolic  acid  and  hot  compresses  (122°  to 
1.31°  F.,  changed  every  ten  minutes,  day 
and  night) .  In  the  course  of  eighteen 
days  more  than  400  Pravaz  syringefuls 
of  3-per-eent.  solution  of  carbolic  acid 
were  given  without  signs  of  intoxication 
appearing.  Alexander  Strubell  (Mun- 
chener  med.  Woch.,  Nov.  29,  '98) . 

The  fact  that  experiments  have  shown 
that  ipecacuanha  added  to  tubes  contain- 


ANTIPYRINE. 


433 


ing  5  cubic  centimetres  of  broth  invaria- 
bly destroy  the  vitality  of  all  the  anthrax 
bacilli  present,  and  no  growth  ensued 
(provided  that  they  contained  no  spores) 
has  suggested  the  use  of  this  drug  as  a 
remedy. 

Ipecacuanha,  locally,  in  form  of  pow- 
der and  internally  in  doses  of  5  grains 
every  four  hours  advocated.  Fifty  cases 
so  treated  without  a  death.  Maskett 
(Med.  Chronicle,  Aug.,  '91). 
Nucleinic  acid  has  also  given  promis- 
ing results  in  the  hands  of  Vaughan. 

Case  of  grave  anthrax  successfully 
treated  with  Marmorek's  serum.  In- 
cision and  curetting  had  been  of  no  use. 
A.  L.  Dupraz  (Archives  Prov.  de  Chir., 
Mar.  1,  1900). 

In  anthrax  and  other  septic  conditions 
general  infection  must  be  prevented,  yet 
no  operation  is  indicated.  Applications 
to  the  carbuncle,  with  fixation  and  in- 
ternal treatment,  suffice.  Operative  in- 
terference may  cause  general  infection; 
yet,  when  abscess  forms,  it  should  be 
thoroughly  evacuated.  A  dry  dressing 
is  advised ;  in  some  cases  iodoform  gauze 
and  pure  carbolic  acid  are  good.  In  all 
but  very  slight  conditions  moist  dress- 
ings are  contra-indicated.  E.  Lexer  (Die 
Therapie  der  Gegenwart,  Jan.,  1903). 
Ehitest  Laplace, 

Philadelphia. 

ANTIPYRINE.— Phenazonum  (Br. 
Ph.);  antipyrinum  (Ger.  Ph.).  Antipy- 
rine  is  an  alkaloidal  product  from  the 
destructive  distillation  of  coal-tar,  dis- 
covered by  Knorr.  It  is  known  chemic- 
ally as  dimethyl-oxy-quinizine  of  phe- 
nyl-dimethyl-pyrazole  (organic  base  from 
oxyphenyl-methyl-pyrazole).  It  is  known 
also  as  analgesine,  methozine,  parodyne, 
phenylone,  and  sedatine.  It  occurs  as 
a  fine,  white,  crystalline  powder,  and  is 
soluble  in  chloroform,  in  an  equal  weight 
of  water,  in  2  parts  of  alcohol,  and  in  50 
parts  of  ether.  It  melts  at  105°  to  113° 
C.  (210°  to  235.4°  F.)  according  to  dry- 
ness.   It  has  antipyretic,  analgesic,  seda- 


tive, styptic,  and  antiseptic  properties. 
The  following  substances  incompatible 
with  antipyrine  are  said  to  precipitate 
the  drug  from  concentrated  solutions: 
Carbolic  acid  in  saturated  solution, 
tannin  (a  white  insoluble  precipitate), 
mercuric  chloride  (white  precipitate 
soluble  in  an  excess  of  water),  infusion 
and  tincture  of  catechu;  infusion,  fluid 
extract,  and  tincture  of  cinchona-bark; 
infusion  of  rose-leaves,  infusion  of  uva 
ursi,  tincture  of  hamamelis,  tincture  of 
iodine  (precipitate  soluble  in  water), 
tincture  of  kino,  tincture  of  rhubarb; 
solutions  of  chloral,  arsenic,  and  mer- 
cury; and  alkalies. 

In  the  following  mixtures  antipyrine 
is  decomposed:  Calomel  forms  with  anti- 
pyrine a  toxic  combination;  antipyrine 
in  decomposed  when  rubbed  up  with 
betanaphthol;  with  chloral,  antipyrine 
forms  an  oleaginous  liquid;  with  sodium 
bicarbonate  it  disengages  the  odor  of 
ether;  with  equal  parts  of  sodium  salicy- 
late it  forms  an  oleaginous  mixture. 

The  following  substances  produce  col- 
oration when  added  to  aqueous  solutions 
of  antipyrine:  Hydrocyanic  acid:  dilute 
solution — yellow;  nitric  acid:  dilute 
solution — pale  yellow;  ammonia  alum: 
dilute  solution — dark  yellow;  amyl-ni- 
trite:  acid  solution  —  green;  nitrous 
ether:  alcoholic  solution  —  green;  fer- 
rous phosphate:  yellow-brown;  ferric 
sulphate:  blood-red;  ferric  chloride: 
blood-red;  syrup  of  iodide  of  iron:  red- 
brown. 

Dose. — The  usual  dose  for  adults  is  15 
grains  in  powder  or  dissolved  in  water, 
syrup,  or  elixir,  every  two  to  six  hours, 
or  four  or  five  times  daily.  The  maxi- 
mum single  dose  for  an  adult  is  20  grains. 
The  maximum  doses  for  children  are:  6 
months  to  1  year,  3  grains;  1  to  3  years, 
4  to  5  grains;  4  to  5  years,  4  ^/a  to  6 
grains;  6  to  8  years,  7  V„  to  9  grains;  10 


424 


ANTIPYEINE.    ADMINISTRATION. 


to  13  years,  9  to  10  V2  grains.  Gener- 
ally, it  will  be  found  that  small  doses, 
repeated  at  intervals  of  two  hours,  are 
attended  with  therapeutic  effects  and 
with  less  danger  of  untoward  symptoms 
than  larger  doses  given  at  longer  inter- 
vals. 

Caution  against  the  simultaneous  use 
of  antipyrine  and  calomel.  Their  reac- 
tions result  in  the  formation  of  a  danger- 
ous amount  of  corrosive  sublimate,  even 
when  ordinary  medicinal  doses  are  given. 
H.  Werner  (Pharm.  Zeit.,  June  10,  '96). 
Antipyrine  and  sodium  salicylate  can- 
not be  dispensed  together  in  powder 
form;  immediately,  or  within  a  short 
time,  liquefaction  takes  place,  and  when 
the  powders  reach  the  patient  he  is 
likely  to  find  no  powder  at  all,  but  only 
thoroughly  soaked  pieces  of  paper.  W. 
J.  Eobinson  (N.  Y.  Med.  Jour.,  Oct.  30, 
'97). 

In  giving  the  drug  the  personal  idio- 
syncrasy of  the  patient  should  be  con- 
sidered, as  well  as  the  integrity  of  the 
urinary  and  cardiac  functions.  A  dose 
which  would  be  safe  for  a  person  with 
healthy  heart  and  kidneys  might  cause 
dangerous  symptoms  in  a  case  where 
these  organs  are  diseased.    (Lepine.) 

Case  of  idiosyncrasy  to  antipyrine. 
Author  suffered  from  migraine  and  used 
to  be  in  the  habit  of  taking  15  gi'ains 
of  antipyrine  during  the  attacks.  These 
were  followed  by  the  occurrence  of  small, 
aphthous  ulcers  on  the  mucous  mem- 
brane of  the  lips,  cheeks,  and  tongue, 
which  healed  very  slowly.  Another  time 
his  lower  lip  became  swollen  and  ffidema- 
tous,  and  in  two  hours  an  ulcer  appeared 
on  the  tongue.  Several  others  shortly 
afterward  formed  on  the  lips  and  cheeks, 
and  took  fourteen  days  to  heal.  In  ad- 
dition he  suffered  from  dermatitis  about 
the  genital  region.  Another  ease  of  the 
same  nature  met  with  in  practice.  In- 
tolerance of  the  same  kind  gradually 
developed  in  him  to  all  drugs  of  the  same 
class,  —  quinine,  antifebrin,  phenacetin, 
and  sodium  salicylate, — which  he  had 
used  to  check  the  migraine.  Steinhardt 
(Ther.  Monat.,  Nov.,  *93). 


Case  of  a  young  man  who  had  often 
taken  antipyrine  without  discomfort 
until  he  was  17  years  of  age,  when  he 
suffered  from  typhoid  fever,  and  devel- 
oped marked  intoleranc  to  this  drug. 
In  the  course  of  the  following  year  he 
took  it  several  times,  once  a  dose  of  15 
grains,  afterward  half  this  dose,  then 
only  3  or  4  grains,  and  finally  between 
1  and  2  grains.  Even  after  the  smallest 
dose  unpleasant  symptoms  appeared.  At 
first  there  were  marked  twitchings  in 
the  genital  and  anal  regions.  In  a  few 
days  there  appeared  here  numerous  blebs, 
which  burst  and  formed  scabs.  On  the 
gums  there  appeared  also  little  blisters. 
The  remarkable  fact  in  this  case  is  that 
intolerance  developed  after  typhoid  fever. 
(Jour,  de  M6d.  et  de  Chir.,  Dec.  25,  '90.) 

A  review  of  cases  in  which  dangerous 
symptoms  or  death  had  followed  sug- 
gests that  antipyrine  should  not  be  given 
in  antipyretic  doses  to  fever  patients, 
because  it  interferes  with  the  action  of 
the  kidneys,  and  that  in  febrile  conditions 
complicated  by  nephritis  (pneumonia, 
typhoid  fever,  tuberculosis,  etc.)  it  is 
contra-indicated.  It  must  be  avoided  in 
true  angina  pectoris,  because  it  acts  in- 
juriously on  the  heart-muscle,  and  there 
is  always  danger  of  cardiac  dilatation  in 
this  affection.  In  the  neuralgic  form  of 
angina  pectoris  there  is  no  reason  for 
preferring  its  hypodermic  use  to  that  of 
morphine.  "Weakness  of  the  circulation, 
too,  is  a  contra-indication  to  antipyrine. 
(Eloy.) 

Warning  against  its  employment  in 
all  cases  in  which  the  kidneys  are  dis- 
eased, since  its  elimination  is  interfered 
with,  and  toxic  effects  might  arise.  Ar- 
teriosclerosis should  not  be  treated  by  it, 
even  when  the  kidneys  are  not  afl'ccted. 
Huchard  (Jour.  Amer.  Med.  Assoc,  July 
7,  "88). 

Contra-indications  for  the  employment 
of  antipyrine:  a  weak  heart;  diphtheria, 
with  phenomena  of  myocarditis;  profuse 
hsemorrhages ;  in  debilitated  subjects; 
convalescence  from  chronic  fevers;  and 
the  night-sweats  of  tuberculous  patients. 


ANTIPYRINE.     PHYSIOLOGICAL  ACTION. 


435 


B.  Martin  (L'Union  M6d.,  Oct.  20,  22,  27, 
■91). 

Persons  suffering  from  erysipelas  seem 
to  be  peculiarly  susceptible  to  antipyrine. 
It  usually  causes  anuria  and  a  profound 
fall  of  temperature,  requiring  caffeine 
and  hot  applications.  Erysipelas  is  one 
of  the  infectious  disease-  in  which  anti- 
pyrine is  contra-indicated.  Spanoudis 
(L'Abeille  Med.,  Mar.  27,  '97). 

Antipyrine  should  never  be  prescribed 
for  veiy  old  people,  for  subjects  attacked 
with  non-compensating  cardiac  lesions, 
or  for  those  in  an  adynamic  condition. 
In  influenza  and  erysipelas  it  should 
always  be  associated  with  quinine,  and, 
in  convalescence,  M'ith  strychnine  or  caf- 
feine. In  arthritic  subjects,  who  are 
nearly  always  dyspeptics,  it  should  be 
associated  with  an  alkali  (sodium  bi- 
carbonate or  sodium  benzoate)  and  pre- 
scribed in  solution.  If  it  cannot  be  taken 
except  in  a  capsule,  the  patient  should 
drink  a  quarter  or  half  a  glass  of  "Vichy 
immediately  after  taking  the  capsule. 
In  tuberculous  subjects  12  grains  at  a 
time  should  not  be  exceeded,  and  the 
condition  of  defervescence  should  be  care- 
fully watched.  It  is  well,  in  this  case, 
to  combine  alcohol  and  antipyrine  and 
give  the  latter  in  solution.  In  diabetic 
subjects  the  association  with  alkalies  is 
obligatory.  In  children  antipj'rine  may 
be  administered  without  inconvenience 
even  in  amounts  proportionately  larger 
than  in  adults,  provided  it  is  given  in 
divided  doses.  This  tolerance  depends  as 
much  upon  the  integrity  of  the  renal 
function  as  upon  the  mode  of  adminis- 
tration, which  should  nearly  always  be 
by  the  solution.  M.  V.  Clement  (Gaz. 
Heb.  de  Mgd.  et  de  Chir.,  Sept.  26,  '97). 

Antipyrine  intoxication  after  the  in- 
gestion of  15  grains  in  the  form  of  mi- 
grainin.  The  symptoms  were  dryness  in 
the  mouth,  painful  redness  and  swelling 
of  the  fingers,  vesicles  on  hard  palate, 
salivation,  purpuric  eruption  on  legs,  ec- 
zema of  scrotum,  oedema  and  vesicles  of 
lower  lips,  oedema  of  prepuce,  fever,  and 
rapid  pulse.  G.  Graul  (Deut.  med. 
AVoch.,  Jan.  19,  '99). 

Three  cases  of  a  remarkable  eruption 
caused  by  antipyrine.  This  eruption  con- 
sists of  dark  blotches  in  the  skin  of  the 


penis,  sometimes  accompanied  by  oedema. 
In  one  case  the  eruption  appeared  four 
and  a  half  hours  after  the  first  dose  was 
taken.  The  patients  were  alarmed,  think- 
ing that  gangrene  of  the  penis  wag  going 
to  follow.  Fournier  (Ann.  de  Derm,  et 
de  Syph.,  Apr.,  '99). 

Physiological  Action.  —  Antipyrine  is 
excreted  by  the  kidneys,  and  may  be 
found  unchanged  in  the  urine.  Perret 
and  Givre  have  shown  that,  no  matter 
what  the  age  of  the  person  may  be, 
elimination  by  the  urinary  tract  begins 
at  the  same  time,  varying  from  three- 
fourths  of  an  hour  to  an  hour.  They 
found,  however,  that  the  elimination  is 
finished  sooner  in  the  child  than  in  the 
adult,  and  likewise  in  the  adult  than  in 
old  age.  The  conditions  causing  accumu- 
lation in  the  system  do  not  influence  in 
any  manner  the  time  of  the  appearance 
of  antipyrine  in  the  urine,  but  notably 
increases  its  duration.  Any  of  the  sub- 
stances producing  coloiation  when  added 
to  aqueous  solutions  may  be  used  as  a 
test  to  detect  the  presence  of  antipyrine 
in  the  urine,  but  ferric  chloride  is  most 
generally  employed  for  the  purpose,  de- 
tecting antipyrine  in  dilutions  as  high  as 
1  to  100,000. 

The  elimination  of  antipyrine  when 
given  by  the  rectum  occurs  from  the 
mucous  membrane  of  the  stomach,  in 
from  one-fourth  to  one-half  hour  before 
taking  place  by  the  kidneys.  P.  Kandi- 
doff  (Wratseh,  No.  13,  '93). 

Antipyrine  appears  in  the  urine  forty- 
minutes  after  its  ingestion  by  the  stom- 
ach and  thirty  minutes  after  its  intro- 
duction by  the  rectum.  Lamanski  and 
Main   (Le  Bull.  Med.,  Jan.  29,  '93). 

Antipyrine  may  be  excreted  from  the 
rectum,  the  mouth,  or  from  the  subcuta- 
neous connective  tissue  when  given  by 
hypodermic  injections. 

When  a  medium  dose  (10  to  15  grains) 
is  given,  we  notice  a  fall  of  temperature, 
from  one  to  five  or  more  degi'ees,  at  the 


426 


ANTIPYRINE.    POISONING. 


time  the  temperature  becomes  very  sub- 
normal. This  reduction  of  temperature 
is  apparently  not  due  to  the  diaphoresis 
induced,  which  is  sometimes  small  in 
amount,  but  by  its  inhibitory  action  upon 
the  heat-regulating  centres  in  the  nerv- 
ous centres.  This  action  is  seen  in  health 
as  well  as  in  disease.  "With  the  reduction 
in  temperature  is  noticed  an  increased 
action  of  the  sweat-glands,  perspiration 
being  seen  first  about  the  forehead  and 
neck,  and  later  upon  the  chest  and  face. 
Chilly  sensations,  which  may  be  experi- 
enced if  the  sweating  is  excessive,  can  be 
removed  or  prevented  by  the  exhibition 
of  stimulants:  atropine  or  agaricin.  Stim- 
ulants will  also  prevent  the  depressing 
action  upon  the  heart. 

With  the  calorimeter  of  d'Arsonval 
heat-dissipation  found  to  be  decreased, 
there  being  a  corresponding  diminution 
in  the  process  of  heat-production.  Des- 
tree  (Jour,  de  Mgd.,  de  Chir.,  et  de 
Pharm.,  July  20,  '88). 

The  reduction  of  temperature  produced 
by  antipyrine  is  exclusively  due  to  in- 
crease of  heat-dissipation,  while  the 
phenomenon  of  heat-production  remains 
unaffected.  Gottlieb  (Arch,  exper.  Path, 
u.  Pharm.,  vol.  xxviii,  H.  3,  4,  '91). 

Antipyrine  produces  a  decided  fall  of 
temperature  in  the  first  hour  after  its 
administration  in  the  fevered  animal; 
this  reduction  is  due  to  a  great  increase 
in  heat-dissipation,  together  with  a  fall 
in  the  heat-production.  Cerna  and  Car- 
ter (Notes  on  New  Remedies,  Sept.,  '92). 

The  pulse  is  generally  reduced  in  fre- 
quency concurrently  with  the  fall  in 
temperature,  but  not  in  the  same  ratio, 
and  sometimes  not  at  all.  The  blood- 
pressure  is  usually  increased  with  the 
fall  of  temperature,  but  is  occasionally 
reduced  by  reason  of  a  dilatation  of  the 
peripheral  blood-vessels.  The  heart -beat 
is  generally  reduced  and  the  force  of  the 
systole  is  lessened,  at  least  to  some  ex- 
tent, and  in  this  lies  the  great  danger 
attached  to  its  use:    a  contrary  efEect  to 


that   produced   by   quinine,   which   sus- 
tains the  heart. 

In  regard  to  the  influence  of  the  drug 
upon  the  secretion  of  urine,  experiments 
have  shown  that  the  quantity  is  dimin- 
ished in  twenty-four  hours;  this  is  also 
the  case  as  regards  the  amount  of  urea 
eliminated  under  its  use. 

Antipyrine  in  doses  of  30  grains  causes 
an  increase  in  the  number  of  leucocytes 
in  the  blood  and  a  decrease  in  the  quan- 
tity of  uric  acid  eliminated  by  the  urine. 
J.  Horbaczewski  (Litzungs  b.  d.  K.  K. 
Wiener  Akademie  der  Wissen.,  p.  101, 
'92). 

Antipyrine,    in    doses    of    30    grains, 

causes  a  diminution  in  the  quantity  of 

uric  acid  eliminated  by  the  urine  and  an 

increase  in  the  number  of  leucocytes  in 

the  blood;    unlike  quinine,   it  does  not 

produce  atrophic  changes  in  the  spleen. 

J.  Horbaczewski  (Bull,  du  Comite  Agric. 

du  Dept.  de  I'Aube,  T.  C,  Sec.  3,  p.  101, 

'92). 

Antipyrine  Poisoning.  —  The  use  of 

antipyrine  is  not  always  void  of  danger. 

Very   unpleasant,   even   dangerous   and 

fatal  results  are  on  record.     The  dose 

does   not   always    determine   the    effect 

produced,  and  it  would  seem  that  some 

persons  are  extremely  susceptible  to  its 

toxic  action.   In  addition  to  idiosyncrasy, 

a  diseased  condition  of  the  brain,  heart, 

or  blood-vessels,  and  especially  of  the 

kidneys  (organs  eliminating  antipyrine) 

seems  to  heighten  the  effects  of  the  drug 

on  the  system,  so  much  so  as  to  interdict 

its  use  altogether. 

Antipyrine   is  a   dangerous   drug.     It 
ought  to  be  scheduled  as  a  poison,  only 
to  be  dispensed  on  a  written  order  from 
a  qualified  medical  practitioner.    By  com- 
bining   some    preparation    of    ammonia 
with  antipyrine,  the  latter  drug  can  be 
prescribed  with  less  fear  of  unpleasant 
sequelae.     H.  W.  McCauUy  Hayes   (Brit. 
Med.  Jour.,  Feb.  1,  '96). 
The  toxic  effects  of  antipyrine  when 
ingested   are,   in   general,   those   of   an 
irritant   poison:    abdominal   pain,   nau- 


ANXIPYRINE.    POISONING. 


427 


sea,  heart-burn,  and  in  some  cases  vom- 
iting, intense  colic,  and  diarrhosa.  These 
effects  may  be  avoided  by  rectal  admin- 
istration of  the  drug.  In  addition  to 
these  effects  upon  the  gastro-intestinal 
tract,  we  notice  a  diminution  of  body- 
heat,  in  some  cases  becoming  subnormal, 
the  skin  becoming  cold,  cyanotic,  and 
covered  with  a  clammy  perspiration, 
.sometimes  followed  by  unconsciousness, 
collapse,  coma,  convulsions,  and  even 
death.  In  rare  cases  an  elevation  of  tem- 
perature follows  its  use  (paradoxical  ac- 
tion), possibly  due  to  interference  with 
renal  function  and  the  presence  of  urea 
or  leuuomaines  in  the  blood;  several  cases 
of  this  action  have  been  reported.  The 
administration  of  15  grains  has  been 
followed,  in  several  cases  reported,  by 
violent  sneezing,  a  copious  watery  dis- 
charge from  the  eyes  and  nose,  constric- 
tion about  the  throat,  loss  of  voice,  and 
dyspnoea,  with  a  sense  of  intense  burn- 
ing in  the  nose,  mouth,  eyes,  ears,  and 
throat  and  distressing  tinnitus  aurium. 
Vertigo  attended  by  dyspnoea,  and  a 
feeble,  fluttering,  and  intermittent  pulse 
are  not  infrequently  observed.  Disturb- 
ance of  the  vasomotor  system  is  observed 
in  some  cases,  resulting  in  cedema  (some- 
times of  the  glottis,  causing  suifocation) 
of  the  extremities  or  face  with  a  dimi- 
nution in  temperature  and  a  tendency  to 
cyanosis  and  collapse. 

Case  of  poisoning  by  antipyrine. 
Within  a  quarter  of  an  hour  after  tak- 
ing a  dose  of  10  grains  the  patient  felt 
vei-j'  ill.  His  face  was  cyancsed,  his  lips 
and  nose  swollen  and  blue^  and  his  eyes 
almost  closed  from  swelling  of  the  eye- 
lids; skin  was  cold  and  clammy;  sweat- 
ing; pulse,  128,  very  weak,  small,  and 
compressible.  Pupils  widely  dilated. 
Administered  5  grains  of  carbonate  of 
ammonia,  Vw,  grain  of  digitaline,  '/» 
grain  of  strychnine,  and  'A  ounce  of 
vinum  aurantii.  The  next  quarter  of  an 
hour  his  condition   improved   as   far   as 


the  symptoms  of  cardiac  depression  were 
concerned.     Recovery.     H.  W.  McCauUy  • 
Hayes  (Brit.  Med.  Jour.,  Feb.  1,  '96). 

Case  of  an  anaemic  girl  of  19,  who  took 
a  draught  containing  5  grains  of  anti- 
pyrine and  7  grains  of  bromide  of  potas- 
sium, with  a  drachm  of  compound  spirit 
of  ammonia.  Toxic  symptoms  appeared 
about  ten  minutes  after  the  draught  was 
taken.  A  few  minutes  later  the  follow- 
ing conditions  were  present:  Cold  shiv- 
ers, severe  and  gasping  dyspnoea ;  the  face 
was  swollen,  especially  about  the  eyes, 
so  much  so  as  to  prevent  any  possibility 
of  opening  them  or  of  seeing,  except 
with  great  difficulty,  the  pupil;  and  the 
body  was  covered  with  a  bright-red  rash, 
like  scarlet  fever,  resembling  that  of 
urticaria,  so  that  it  presented  wheals, 
which  were  of  different  sizes:  from  that 
of  a  small  papule  to  some  as  large  as 
five-shilling  pieces.  The  temperature  in 
the  axilla  was  97°  F.,  and  the  pulse, 
which  was  very  intermittent,  was  only 
50.  She  complained  of  no  pain.  The 
tongue  was  very  dry.  The  lips  and  gen- 
eral aspect  were  decidedly  cyanotic. 
Stimulants,  with  strychnine  and  digitalis, 
were  given.  The  shivering  passed  off  in 
about  three  hours,  but  the  other  symp- 
toms continued  for  about  eight  hours. 
The  rash  did  not  disappear  for  thirty 
hours.  E.  Webster  (Lancet,  Jan.  30, 
'97). 

Poisoning  by  antipyiine  in  a  middla- 
aged  woman,  convalescent  from  typho- 
malarial  fever.  After  taking  10  grains 
of  antipyrine,  20  minims  of  spiritus  am- 
moniae  aromaticus,  and  1  ounce  of  water, 
she  was  very  pale,  but  not  cyanotic;  no 
swelling  of  the  eyelids,  but  almost  com- 
plete loss  of  sight;  rash,  which  disap- 
peared in  about  eighteen  hours,  resem- 
bling that  of  urticaria.  Patient  rallied 
well  on  the  administration  of  hot  coffee 
and  whisky.  Recovery.  F.  G.  Wallace 
(Lancet,  Feb.  6,  '97). 

Case  of  a  woman,  aged  50  years,  poi- 
soned by  7  grains.  After  an  hour :  swell- 
ing and  redness  of  the  upper  lip.  After 
three  hours :  pain  in  the  eyes ;  paralysis, 
swelling,  and  smarting  of  the  tongue. 
Speech  difficult;  salivation.  An  hour 
later:  chilliness,  sensations  of  heat;  and, 
later,  syncope,  vomiting,  and   diarrhcea. 


428 


ANTIPYEINE.    POISONING. 


The  next  morning  there  was  an  eruption 
upon  the  face^  arms^  hands,  and  thighs 
which  resembled  scarlet  fever,  with 
marked  burning  and  itching  about  anus 
and  vulva  that  gradually  extended  over 
the  whole  body.  These  symptoms  grad- 
ually disappeared  in  two  weeks.  Severe 
desquamation.  Scheel  (Ther.  Monat.,  H. 
3,  S.  161,  '97). 

Case  showing  that  antipyrine  may  un- 
expectedly prove  poisonous  in  a  small 
dose  (7^/,  gi-ains,  in  this  instance)  in  a 
person  who  has  shown  no  special  idiosyn- 
crasy toward  it,  after  taking  the  drug 
on  many  previous  occasions.  Eisenmann 
(Tlier.  Monat.,  Apr.,  '97). 

Case  in  which  a  dose  of  10  grains  of 
antipyrine  caused  acute  pain  in  the  ab- 
domen, emesis,  and  rapid  swelling  of  the 
face,  almost  closing  the  eyes.  This  was 
followed  by  two  periods  of  collapse,  one 
lasting  a  half-hour.  Recovery  followed. 
The  patient  had  taken  similar  doses  be- 
fore with  no  ill  effect.  H.  Blakeney 
(Brit.  Med.  Jour.,  July  8,  '99). 

The  toxic  action  of  antipyrine  on  the 
blood  seems  to  be  a  transformation  of  its 
oxyhasmoglobin  into  methEemoglobin. 

The  action  of  antipj'retics  on  the  blood 
when  administered  in  toxic  doses  may 
be  summed  up  as  a  transformation  of 
oxyhaamoglobin  into  methsemoglobin.  A 
phase  of_  anDemia,  or  diminution  of  oxy- 
hfemoglobin,  precedes  the  accumulation 
of  methtemoglobin.  In  this  period  there 
is  at  the  same  time  production  and  elimi- 
nation of  methffimoglobin;  if  elimination 
be  hindered  or  transformation  be  too 
rapid,  phenomena  of  cyanosis  may  be 
produced  which  must  be  distinguished 
from  those  of  the  period  of  intoxication. 
Hgnocque  (La  Semaine  Med.,  Mar.  27, 
'95). 

Blood  of  frogs  and  blood  taken  from 
the  cyanosed  lips  and  other  parts  of  a 
rabbit,  both  ante-  and  post-  mortem,  ex- 
amined spectroscopically.  The  rabbit 
had  died  from  toxic  effects  of  antipyrine, 
yet  the  spectrum  of  methsemoglobin  was 
certainly  not  present.  Andres  Halliday 
(Montreal  Med.  Jour..  July,  '97). 

The  poisonous  effects  of  antipyrine 
upon    the    nervous    sj'stem    have    been 


studied  by  Langlois  and  Guibaud.  By 
graduated  doses,  given  to  animals  whose 
spinal  cord  had  been  divided  below  the 
medulla  oblongata,  they  discovered  sev- 
eral stages  of  antipyrine  poisoning.  First, 
a  cerebral  stage,  in  which  clonic  epilepti- 
form convulsions  are  limited  to  the  head; 
second,  a  cerebro-spinal  stage,  in  which 
the  head  is  still  affected  with  clonic  con- 
vulsions, while  the  trunk  is  attacked  with 
one  or  more  tonic  spasms  (opisthotonos); 
third,  a  cerebral  stage,  with  spinal  hyper- 
irritability,  in  which  the  shocks  caused 
by  the  clonic  convulsions  of  the  head  set 
up  violent  reflex  movements  of  the  body, 
comparable  to  the  spasms  of  strychnine 
poisoning;  fourth,  the  reflexes  of  the 
head  disappear  at  the  same  time  as  those 
of  the  trunk.  Antipyrine  has,  then,  an 
elective  action  in  the  higher  centres,  and 
this  explains  why  its  sedative  action  is 
more  marked  in  head  affections  than  in 
spinal. 

Experiments  apparently  proving  that 
the  main  action  of  the  drug  is  upon  the 
neiwous  sj'stem,  not  in  its  peripheral  por- 
tions, but  rather  upon  the  spinal  cord 
and  brain.  Batten  and  Bokenham  (Brit. 
Med.  Jour.,  June  1,  'o9). 

Experiments  sustaining  Batten  and 
Bokenham  as  to  the  effect  of  the  drug 
upon  the  spinal  cord,  and  in  its  local 
and  general  action  as  a  sedative  to  the 
sensory  nerves.  Also  in  accord  with 
most  observers  in  the  statement  that 
antipyrine  does  not  affect  the  circulation 
to  any  extent  in  moderate  doses.  Simon 
and  Hoeh  (Johns  Hopkins  Hosp.  Bull.; 
Apr.,  '90). 

The  deleterious  effects  manifested  in 
the  cutaneous  system  are  very  varied. 
There  may  be  merely  a  sensation  of  great 
itching  or  burning  without  the  appear- 
ance of  any  eruption,  which  disappears 
rapidly  upon  the  discontinuance  of  the 
drug.  If  an  eruption  appears,  it  may 
take  the  form  of  erythema,  urticaria, 
petechife,  or  papule,  or  resemble  in  ap- 


ANTIPYRINE.     POISONING. 


429 


pearance  one  of  the  exanthemata: 
measles,  scarlatina,  etc.  In  rare  cases 
we  note  discoloration  of  the  face  and 
of  the  mucous  membrane  of  the  mouth, 
swelling  of  lips,  tongue,  and  salivary 
glands,  with  epileptoid  attacks,  amauro- 
sis, tinnitus,  deafness,  and  delirium. 
In  rarer  cases  the  ingestion  of  anti- 
pyrine  is  followed  by  the  appearance 
of  albuminuria,  hasmaturia,  ischuria,  or 
strangury. 

Urticaria  produced  rapidly  by  a  single 
dose  of  10  grains  of  antipyrine.  E. 
Knight  (Brit.  Med.  Jour.,  May  18,  '95). 
Case  in  which  entire  surface  of  the 
body  was  covered  with  a  copious  erup- 
tion exactly  resembling  in  appearance 
that  of  a  severe  case  of  measles;  the 
face  and  eyelids  were  also  swollen,  after 
taking  10-grain  powders  of  antipyrine 
twice  daily  for  three  weeks.  No  symp- 
toms of  cardiac  depression  appeared  to 
be  produced  by  the  drug.  Webber  (Lan- 
cet, .June  6,  '96). 

Case  of  a  gouty  person  of  65  years, 
who  had  often  taken  antipyrine  without 
bad  effects.  One  day  a  dose  of  30  grains 
caused  aphthous  stomatitis,  while  an  in- 
jection of  15  grains  produced  an  ulcera- 
tive stomatitis  with  a  purpural  eruption. 
Dalche   (Med.  News,  Feb.   13,  '97). 

Case  of  a  woman  of  33  years,  who, 
several  hours  after  the  ingestion  of  anti- 
pyrine, developed  a  general  pemphigus- 
like eruption  upon  the  skin  and  also 
upon  the  buccal  mucous  membrane. 
This  condition  lasted  ten  days.  There 
was  also  a  scanty  urine,  but  no  albu- 
minuria. Opinion  that  eruptions  ai-e 
only  likely  to  occur  in  persons  with  renal 
lesions.  Lyon  (L'Abeille  M^d.,  Mar.  27, 
'97). 

Case  in  which  there  was  oedema  of  the 
lower  extremities  and  the  vulva,  with 
blebs  forming  under  the  skin  after  full 
doses.  These  symptoms  ceased  when 
the  drug  was  stopped.  Goldschmidt 
(L'Abeille  M6d.,  Mar.  27.  '97). 

Case  of  a  woman  who  had  syphilis 
in  1894,  for  which  she  ^^•as  thoroughly 
treated.  Near  three  years  later  syphi- 
litic manifestations  appeared,  which  dis- 
appeared   under    treatment.       In     April, 


1898,  she  took  7  'A  grains  of  antipyrine 
on  account  of  headache,  and  on  following 
day  had  a  crop  of  vesicles  in  the  mouth, 
which  soon  disappeared.  A  few  days 
later  she  took  another  dose  of  7  'A  grains 
of  antipyrine.  In  the  same  evening  she 
shivered,  and  was  feverish,  and  had  an 
urticarial  eruption  over  the  body.  On 
the  next  day  there  were  numerous  ves- 
icles on  the  mucous  membrane  of  the 
cheek,  soft  and  hard  palate,  upper  and 
lower  lips,  and  also  on  the  vaginal  mu- 
cous membrane.  Patient  thought  this 
relapse  of  the  syphilis.  In  four  days 
vesicles  began  to  dry  up,  but  food  was 
taken  with  difficulty.  Urticaria-like  rash 
had  now  disappeared.  Nothing  but  sim- 
ple treatment  used.  Immerwahr  (Ber- 
liner klin.  Woch.,  Aug.  22,  '98). 

In  some  cases  there  is  a  marked  re- 
semblance between  antipyrine  poisoning 
and  the  algid  stage  of  cholera. 

Case  in  which  there  was  severe  col- 
lapse, cold  extremities,  vomiting,  hoarse 
voice,  and  sunken  eyes.  The  stools,  how- 
ever, were  solid,  and  there  was  a  deep, 
rose-red  rash  on  the  patient's  body.  His 
radial  pulse  could  not  be  felt.  He  an- 
swered questions  slowly,  complained  of 
headache  and  noises  in  his  ears,  and  had 
disturbed  vision.  He  had  taken  2  V2 
drachms  in  15-grain  doses  twice  daily. 
Recovery  under  the  use  of  stimulants. 
Guttmann  (Ther.  Monat.,  Oct.,  '92). 

Case  of  a  girl  of  20  years,  who  took 
81  grains  of  antipyrine  for  the  relief  of 
headache.     She   did  not   lose   conscious- 
ness, but  the  pulse  became  almost  imper- 
ceptible, reaching  200  per  minute.     She 
recovered    under    absolute    rest,    strong 
coffee    internally,     and    ice     externally. 
Krysinski     (Gazeta    Lekarska,    No.    39, 
'93). 
The  dangerous  and  uncertain  action 
of    antipyrine    in    many    cases    renders 
precaution  highly  necessary.     When  the 
drug  is  known  to  disagree  its  use  should 
be  avoided.    When  disease  of  the  heart, 
functional  or  organic,  or  of  the  kidneys 
is  present,  antipyrine  should  not  be  given 
or  if  necessary  or  expedient,  it  should  be 
carefully  guarded  by  administering  stim- 


430 


ANTIPYRINE.    LOCAL  USE. 


ulants  simultaneously.  During  lactation 
antipyrine  should  not  be  given  unless  we 
wish  to  control  the  function  or  cause  the 
milk  to  disappear. 

Antipyrine  in  nineteen  cases  to  sup- 
press the  lacteal  secretion.  It  was  given 
every  two  hours  in  capsules  containing 
4  grains,  and  a  longer  interval  was 
allowed  to  pass  between  the  dose  which 
preceded  and  that  which  followed  the 
two  meals  of  the  day.  The  results  in 
all  the  cases  were  very  favorable.  After 
the  absorption  of  the  antipyrine  the 
breasts  became  empty  and  soft,  and  the 
lacteal  secretion  was  completely  ex- 
hausted. Antipyrine  is  one  of  the  most 
inoffensive  medicaments  for  the  suppres- 
sion of  the  lacteal  secretion  known. 
Guibert  (Jour,  des  Prat.,  Apr.  17,  '97). 

Antipyrine  certainly  passes  in  a  nat- 
ural state  into  the  milk.  Given  in  large 
doses,  in  two  capsules  each  containing 
15  grains,  at  intervals  of  two  hours,  it 
may  be  detected  in  the  milk  in  from  five 
to  eight  hours  after  its  ingestion,  while 
from  nineteen  to  twenty-three  hours 
afterward  none  can  be  found;  hence 
elimination  lasts  eighteen  hours  at'  the 
maximum.  The  antipyrine  during  this 
time  passes  into  the  milk  only  in  an  ex- 
cessively weak  proportion,  very  much 
less  than  fifty  parts  in  a  thousand;  it 
is  only  in  exceptional  conditions — for 
instance,  when  GO  gi-ains  are  adminis- 
tered in  sixteen  hours — that  it  per- 
ceptibly reaches  this  proportion.  It  does 
not  influence,  in  any  way,  the  quality  of 
the  milk  and,  particularly,  the  lactose, 
the  casein,  or  the  fat.  It  seems  to  have 
no  action  at  all  on  the  secretion,  which 
always  remains  very  abundant,  provided 
the  woman  continues  to  nurse.  From 
the  absence  of  general  symptoms  and 
from  examinations  of  the  weight,  the  in- 
finitesimal quantity  absorbed  by  the 
nursling  does  not  seem  to  have  any  un- 
favorable action.  M.  G.  Fieux  (Bull. 
M6d.,  Sept.  5,  '97). 

Arteriosclerosis  and  depressed  condi- 
iions  of  the  system  (typhoid  fever  asso- 
ciated with  weak  heart,  typhoid  pneu- 
monia, etc.)  centra-indicate  the  use  of 
antipyrine. 


Treatvient  of  Antipyrine  Poisoning. — 
If  a  patient  is  already  suffering  from 
antipyrine  poisoning  our  chief  reliance 
must  be  placed  upon  stimulants:  brandy, 
ether,  ammonia,  atropine,  and  heat  ap- 
plied to  the  extremities  seem  best  to 
meet  the  indications.  As  the  symptoms 
are  those  of  collapse,  all  efforts  should 
tend  toward  the  restoration  of  body-heat 
and  normal  heart-action.  The  presence 
of  any  renal  difficulty  will  suggest  its 
own  appropriate  treatment,  in  addition 
to  that  used  primarily  to  combat  the 
toxic  effects  of  the  antipyrine  on  the 
heart.  Sodium  bicarbonate  is  recom- 
mended as  an  antidote  to  antipyrine 
by  Lepine,  of  Lyons,  who  prefers  it  to 
atropine. 

Local  Use.  —  Saint-Hilaire  and  Cou- 
pard  have  employed  antipyrine  locally 
in  affections  of  the  throat  and  larynx 
attended  with  symptoms  of  exaggerated 
sensibility,  and  have  demonstrated  its 
anaesthetic  properties.  They  advise  a 
solution  of  1  part  of  the  drug  to  2  V, 
parts  of  distilled  water,  used  in  an  atom- 
izer. Cazeneuve,  of  Lyons,  has  found 
antipyrine  serviceable  in  cystitis  with 
ammoniacal  urine  used  in  a  d-per-cent. 
solution.  The  pain  is  diminished  and 
the  character  of  the  urine  modified. 

For  operations  in  the  pharynx  and 
larynx,  a  10-per-cent.  solution  of  cocaine 
should  be  applied,  followed  by  parenchy- 
matous injection  of  50-per-cent.  anti- 
pyrine, the  dose  of  the  latter  being  3  to 
6  grains.  Complete  local  ansesthesia  en- 
sues in  from  10  to  15  minutes  and  lasts 
8  to  12  hours.  Wroblewski  (Medicine, 
Feb.,  '98). 

In  cases  of  acute  tonsillitis  a  gargle, 
composed  of  2  V2  drachms  of  antipyrine, 

2  V2  drachms   of  chlorate   of   potassium, 

3  ounces  of  peppermint-water,  and  8 
ounces  of  distilled  water,  is  useful  when- 
ever the  painful  crises  occur. 

As  a  substitute  for  cocaine  in  a  num- 
ber of  eases  of  urethrotomy,  a  10-per- 
cent, solution  of  antipyine  in  1-per-ceiit. 


ANTIPYEINE.    HYPODERMIC  USE.    THERAPEUTICS. 


431 


solution  of  carbolic  acid  used.  The  solu- 
tion appears  to  be  quite  as  efficacious  as 
cocaine.  The  solution  should  be  fresh, 
and  should  be  allowed  to  remain  in  tlie 
urethra  for  ten  minutes,  as  a  rule.  Un- 
like cocaine,  the  styptic  effect  of  anti- 
pyrine  is  not  followed  by  vascular  re- 
laxation and  often  almost  uncomfortable 
haemorrhage.  G.  Frank  Lydston  (Jour. 
Cut.  and  Genito-Urin.  Dis.,  May,  '98). 

As  an  anassthetic  in  cases  of  parturi- 
tion, antipyrine  is  useless  for  the  pains 
of  a  perfectly  normal  labor,  but  finds 
its  chief  value  in  those  cases  where  the 
pains  are  so  excessive  as  to  reflexly  inter- 
fere with  the  proper  uterine  contractions. 
It  is  also  useful  when  the  liquor  amnii 
has  been  discharged  too  early  and  where 
there  is  rigidity  of  the  os.  In  regard  to 
the  second  stage  of  labor,  antipyrine  is 
useless.  There  is  evidence,  however,  that 
antipyrine  has  considerable  ability  to  re- 
lieve the  so-called  after-pains.  It  is  also 
seemingly  a  fact  that  antipyrine  may  be 
used  with  some  success  for  the  purpose  of 
quieting  a  tendency  to  the  development 
of  pains  before  the  full  term  has  been 
reached.  If  it  is  intended  to  use  anti- 
pyrine for  the  purpose  of  arresting  a 
threatened  miscarriage,  then  its  dose 
must  be  very  large:  as  much  as  30  or 
40  grains  given  in  two  or  three  doses  of 
15  grains  each,  at  half-hour  or  hour  in- 
tervals.   (Misrachi,  Hare.) 

Antipyrine  has  a  powerful  haemostatic 
action  when  applied  locally.  It  acts  by 
vasoconstriction  and  retraction  of  the 
tissues,  with  the  formation  of  a  minute 
clot,  which  is  extremely  retractile  and 
aseptic.  In  epistaxis  antipyrine  may  be 
employed  in  a  20-  to  50-per-cent.  solu- 
tion to  the  bleeding-point  by  means  of  a 
tampon.  For  ordinary  use  as  an  haemo- 
static, a  10-per-cent.  solution  is  sufficient. 
Park,  of  Buffalo,  advises  a  sterilized  5- 
per-cent.  solution  used  as  a  spray,  on 
compress,  or  as  injection. 


Antipyrine  is  particularly  indicated  ia 
epistaxis,  in  a  Vs  or  Vo  solution  to  the- 
bleeding-point   by   means   of   a    tampon. 
For   ordinary   use   as   an   haemostatic   a 
Vio  solution  is  sufficient.     It  is  also  of 
value    in   dental,   tonsillar,    and    uterine 
htemorrhages.      X.     Grfipin     (These     de- 
Paris,  .July,  '95). 
Hypodermic  Use. — Antipyrine  has  been 
used  subcutaneously  in  various  afEections, 
but  its  use  in  this  way  is  followed  by  ex- 
cruciating pain,  which  lasts  about  half  a 
minute,  and  by  abscess  and  gangrene  in 
some  cases.    Such  injections  are  believed 
to  be  particularly  injurious  where  neu- 
ritis is  the  prominent  lesion. 

Since    the    beginning    of    hypodermic 
treatment,    some    way    of   administering- 
quinine   in   this   way   needed,   especially 
in  severe  malaria.    The  difficulty  may  be 
overcome    by    using    Laveran's    formula, 
(hydrochlcrate    of    quinine,    3;     antipy- 
rine,   2;     distilled    water,    6),    giving    a 
oO-per-cent.  solution,  of  Avhich  the  injec 
tion   is  painless.     This   solution,  exten- 
sively used  by   Blum   in   1894  during  a 
severe  malarial  epidemic  in  Algiers,  wis 
always    found    satisfactory       Santesson 
(Deut.  med.  Woch.,  B.  2,  Sept.,  '97). 
Therapeutics. — As  already  stated,  anti- 
pyrine is  especially  useful  in  reducing- 
very  high  temperature  when  unassociated 
with  weak  heart.     For  this  reason  it  is 
valuable  in  the  typhoid  fever  of  children. 
It  not  only  causes  the  desired  reduction 
in  temperature,   but   also   has   a   happy 
effect  in  calming  the  restlessness  and  dis- 
tress caused  by  the  action  of  the  toxins 
upon  the  nervous  system.     In  the  pneu- 
monia of  children  it  has  been  found  to 
be  eqtialljf  valuable,  and  it  is  a  desirable 
remedy  in  the  fever  accompanying  the 
exanthemata  (measles,  scarlatina,  etc.). 

In  healthy  children  antipyrine  is  the 
most  active  drug  in  causing  perspiration ; 
next  in  activity  is  phenacetin;  sodium 
salicylate  and  quinine  show  scarcely  any 
influence  whatever;  acetanilid  causes  a 
diminution.  In  febrile  children  acetan- 
ilid    increases    the     perspiration     most.;. 


432 


ANTIPYRINE.     THERAPEUTICS. 


antipyrine  not  to  the  same  degree;   while 
sodium  salicylate,  quinine,  and  phenac3- 
tin   cause   suppression   of   the   secretion. 
Ssokolow  (Wratsch,  Nos.  14,  16,  21,  '93). 
In  influenza  it  not  only  controls  the 
febrile  movements,  but  relieves  the  pain 
and  quiets  the  nervous  system,  but  its 
depressing  effects  are  sometimes  harm- 
ful.   In  the  hectic  fever  of  tuberculosis 
it  will  sometimes  be  useful;    but,  as  it 
influences  the  extension  of  the  disease 
but  slightly,  if  at  all,  and  causes  profuse 
diaphoresis  and  depression,  other  reme- 
dies are  to  be  preferred. 

Nervous  Disobdees.  —  It  is  in  the 
treatment  of  neuralgia  that  antipyrine 
finds  its  best  place.  In  hemierania,  sci- 
atica, lumbago,  the  fulgurant  pains  of 
locomotor  ataxia,  the  neuralgic  pains  of 
dysmenorrhoea  when  of  ovarian  origin, 
and  in  pains  of  nervous  origin  generally, 
antipyrine  will  be  found  of  great  value, 
being  both  efiieient  and  prompt  in  its 
action.  Small  doses,  from  5  to  10  grains 
every  four  hours  are  generally  efiieient. 
If  ineffectual,  the  dose  should  be  in- 
creased with  caution,  or  the  interval 
between  the  doses  be  shortened.  In  spas- 
modic conditions  referable  to  the  nervous 
system,  bronchial  asthma,  laryngismus 
stridulus,  pseudo-angina  (not  in  true 
angina),  and  idiopathic  epilepsy  the  fol- 
lowing combination  has  been  recom- 
mended by  H.  C.  "Wood: — 
]^  Antipyrine,  6  grains. 

Ammonium  bromide,  30  grains. — 
M. 
To  be  administered  three  times  a  day. 

Forty-three  cases  of  idiopathic  epi- 
lepsy, in  which  the  most  excellent  re- 
sults were  obtained  by  a  combination  of 
antipyrine  and  bromide  of  ammonium, 
as  first  suggested  by  H.  C.  Wood.  The 
combination  did  not  fail  to  give  relief 
in  a  single  one  of  the  cases  reported, 
and  neither  bromism  nor  the  disagree- 
able effects  often  produced  by  antipy- 
rine were  observed.     The  dose  employed 


in  adults  was  6  grains  of  antipyrine  and 
20  grains  of  bromide  of  ammonium  three 
times  a  day.  Charles  S.  Potts  (Univ. 
Med.  Mag.,  No.  1,  '90). 

Beneficial  efi'ects  in  forty  out  of  sixty 
cases,  but  in  three-fifths  of  these  cases 
the  affection  recurred.  One-half  to  1  V2 
drachms  weW  tolerated  for  some  weeks. 
Leroux  (Revue  Men.  des  Mai.  de  I'En- 
fance,  June,  '91). 

[Antipyrine  in  15-grain  doses  is  prob- 
ably the  best  of  all  drugs  in  systematic 
dysmenorrhoea,  especially  if  accompanied 
by  headache.  E.  E.  Montgombby,  Assoc. 
Ed.,  Annual,  '94.] 

Tried  in  an  obstinate  case  of  puer- 
peral coccygodynia  of  two  years'  dura- 
tion in  which  extirpation  of  the  coccyx 
was  seriously  contemplated.  Immedi- 
ately after  the  first  injection  of  a  Pravaz 
syringeful  the  pain  markedly  decreased, 
while  after  a  third  it  disappeared  al- 
together and  never  recurred.  Goenner 
(Corresp.  f.  Sehweizer  Aerzte,  Jan.  25, 
'95). 

Case  of  exophthalmic  goitre  with  pe- 
culiar eye-symptoms.  Under  antipyrine 
treatment  retraction  of  the  upper  lid 
(Stellwag's  symptom)  disappeared,  while 
failure  of  lid  to  descend  upon  downward 
movement  of  the  eye  (Graefe's  symp- 
tom) remained  unchanged.  J.  Hinshel- 
wood  (Brit.  Med.  Jour.,  Aug.  20,  '98). 

Antipyrine  is  essentially  a  nervine, 
and  acts  as  an  analgesic  and  antispas- 
modic. In  pertussis,  therefore,  it  is 
plainly  indicated.  By  diminishing  the 
irritability  of  the  superior  laryngeal 
nerve,  which,  by  reflex,  produces  the 
cough,  it  arrests  the  attacks  of  cough- 
ing and  prevents  secondary  symptoms. 
This  action  on  the  nervous  element  of 
the  cough  is  the  least  disputed  of  the 
effects  of  antipyrine  in  pertussis.  Of 
eighteen  patients  seen  by  le  Goff,  in 
seventeen  the  number  of  attacks  and 
their  intensity  diminished  considerably, 
and  in  nine  recovery  occurred  in  less 
than  twenty-five  days,  thus  considerably 
redu.cing  the  duration  of  the  disease. 
Antipyrine  being  an  antiseptic,  the  in- 


ANTIPYRINE.    THERAPEUTICS. 


433 


fectious  principle  of  the  disease  is  also 
reached. 

Fifteen  cases  treated  with  antipyrine 
with  marlced  success,  the  drug  proving 
inefficient  in  only  one  instance.  In  some 
cases  the  eflects  were  really  astonishing; 
this  was  especially  the  fact  when  treat- 
ment was  commenced  in  the  early  stages, 
at  a  time  when  medication  is  generally 
useless.  In  may  instances  the  disease 
appeared  to  be  aborted,  and  in  others 
it  was  rendered  so  mild  as  to  be  insig- 
nificant. J.  P.  C.  Griffith  (Ther.  Gaz., 
Feb.  15,  '88). 

Antipyrine  employed  in  300  cases  of 
pertussis  in  which  196  patients  were 
cured  or  benefited.  The  average  dura- 
tion of  the  treatment  was  thirty-five 
days.  From  5  to  15  grains  for  children 
up  to  3  years  of  age,  and  from  30  to  60 
grains  for  older  children  and  adults. 
The  only  symptom  observed  to  follow 
the  use  of  antipyrine  is  albuminuria, 
which  appeared  in  two  eases;  it  dis- 
appeared, however,  rapidly  after  the 
cessation  of  the  use  of  the  drug  and  the 
establishment  of  a  milk  diet.  Le  Gofl 
(Gaz.  Heb.  de  Med.  et  de  Chir.,  Oct.  22, 
'96). 

In  mental  diseases  antipyrine  is  con- 
tra-indicated, its  depressing  influence 
upon  the  nervous  system  tending  to 
aggravate  the  pathological  process. 

It  sometimes  prevents  hallucinations 
and  other  sensory  disturbances  of  reflex 
origin.  In  most  cases,  however,  no  effect 
is  produced  or  the  symptoms  are  aggra- 
vated. Marandon  de  Montyel  (Bull.  G6n. 
de  Ther.,  Apr.  30,  '93). 

Antipyrine  in  doses  of  15  grains  re- 
newed in  two  hours  recommended  to 
produce  sleep.  One  to  1  'A  drachms 
frequently  given  per  day  for  a  fortnight 
at  a  time,  without  ill  effects.  J.  B. 
Tuke  (Edin.  Med.  Jour.,  Feb.-June,  '94). 

Eheumatism.  —  In  the  treatment  of 
iheumatism  and  gout  antipyrine  holds  a 
well-recognized  position  of  merit,  reliev- 
ing the  acute  pains  incident  to  those 
affections  and  controlling  the  fever  as 
well.    It  is,  however,  less  desirahle  than 

1- 


the  salicylates  in  rheumatism  or  colchi- 
cum  in  gout,  and,  moreover,  is  not  de- 
void of  serious  danger  if  there  be  any 
lesion  of  the  heart  or  blood-vessels. 

It  often  se€ms  to  act  specifically  in 
acute  and  subacute  rheumatism,  after 
salicylic  acid  has  failed.  R.  Hirsch 
(Ther.  Monat,  Oct.,  '88). 

Case  in  which  the  temperature  twice 
rose  to  106°  F.,  and  was  reduced  by  10- 
graiu  doses  of  antipyrine.  A.  E.  God- 
frey (Brit.  Med.  Jour.,  Nov.  4,  '93). 

Antipyrine  used  subcutaneously :  15 
minims  to  30  minims,  followed  by  mass- 
age at  the  point  of  injection,  used  in 
130  cases  of  lumbago;  122  cured.  The 
syringe  should  be  carefully  cleansed  after 
use,  as  the  antipyrine  will  ruin  the  in- 
strument if  allowed  to  remain.  Excru- 
ciating pain  is  produced,  but  it  continu  s 
but  half  a  minute.  Bergquist  (Eira,  vol. 
xiv.  No.  3,  '95). 

Diabetes. — Antipyrine  has  been  rec- 
ommended in  the  treatment  of  this 
affection,  hut  its  merits  as  regards  the 
permanency  of  results  have  not  been 
sustained  by  the  experience  of  clinicians 
at  large.  Its  continued  use  is  likely  to 
give  rise  to  untoward  symptoms. 

It  is  valuable  in  diabetes,  the  glyco- 
suria and  other  symptoms  promptly  and 
markedly  diminishing  under  the  use  of 
the  drug.  Pousson  (Jour,  de  Med.  de 
Bordeaux,  Oct.  11,  '91). 

While  the  favorable  influence  exercised 
is  not  to  be  doubted,  the  gastric  intoler- 
ance manifested  by  a  number  of  cases 
prevented  its  continuance.  Vergely 
(Jour,  de  M£d.  de  Bordeaux,  Oct.  13, 
'91). 

Antipyrine,  in  doses  of  from  5  to  7  Vs 
grains,  must  not  be  continued  more  than 
eight  to  ten  days.  J.  Mayer  (Centralb. 
f.  d.  Gesammte  Ther.,  July,  '92). 

C.  Sumner  "Witheestine, 

Philadelphia. 

ANTITOXINS.     See  Diphtheria, 
Tuberculosis,    and    other    diseases    in 
which  they  are  used. 
-28 


434 


APHASIA.     VARIETIES.     SYMPTOMS. 


APHASIA.  —  From  Gr.,  a,  priv.,  and 
^rjiii  OT  <^dcj,  I  speak. 

Synonyms. — Aphrosia;    alalia. 

Definition. — A  partial  or  total  loss  of 
the  power  of  expressing  one's  self  in 
speech  or  of  understanding  speech,  which 
is  dependent  upon  cerebral  disorder. 

Varieties. — There  are  two  chief  divi- 
sions of  the  aiiection:  motor,  or  emissive 
or  projective,  aphasia  and  sensory,  or 
receptive  or  subjective,  aphasia.  Each 
of  these  varieties  includes  at  least  two 
elementary  forms:  aphemia  and  agra- 
phia, as  motor  siibdivisions,  and  visual 
aphasia,  or  word-blindness  (alexia),  and 
auditory  aphasia,  or  word-deafness,  as 
subvarieties  of  sensory  aphasia.  The 
motor  aphasia  may  be  complete  (aphe- 
mia) or  there  may  be  only  some  partial 
defect  in  the  emissive  mechanism  of 
speech  (dyslexia,  paralexia,  articulative 
ataxia,  paraphasia,  paralalia).  The  agra- 
phia may  likewise  be  complete  (agraphia) 
or  partial  (paragraphia,  dysgraphia). 
Pantomimic  speech,  so  called, — which  is 
an  emissive  form  of  speech  in  gestures, 
signs,  etc., — may  be  affected  totally 
(amimia)  or  partially  (paramimia)  also. 
The  more  elaborate  subdivisions  of  sen- 
sory aphasia  are  based  upon  qualitative 
rather  than  quantitative  impairment.  In 
the  older  literature  all  forms  of  sensory 
aphasia  were  referred  to  collectively  un- 
der the  term  "amnesic  aphasia,"  which 
included  loss  of  the  pictorial  memory  of 
letters  and  words  and  of  the  sounds  of 
letters,  words,  and  music.  It  included, 
also,  loss  of  the  power  of  understanding 
the  meaning  of  figures,  written  music, 
and  other  symbols.  In  the  more  recent 
literature  of  the  subject  the  term  "am- 
nesic aphasia"  has  been  rather  arbitrarily 
restricted  to  a  loss  of  the  naming  rather 
than  the  ideational  functions  of  speech- 
memory.  Loss  of  the  ideational  faculty 
is  expressed  by  the  term  "apraxia"  (mind- 


er soul-  blindness).  Both  sensory  and 
motor  aphasia  may  be  divided,  as  regards 
the  anatomical  basis,  into  the  cortical 
and  subcortical  varieties.  The  terms 
"conceptional"  and  "conductive"  are 
practically  of  identical  significance  with 
the  terms  "cortical"  and  "subcortical." 
Symptoms. — Motoe  Aphasia  (Aphe- 
mia).—  In  motor  aphasia  the  voluntary 
act  which  must  be  carried  out  to  give 
expression  to  thought  by  the  phonetic  co- 
ordination of  the  muscles  of  the  larynx, 
tongue,  soft  palate,  and  lips  is  not  per- 
formed. The  patient  is  seldom  unable 
to  produce  sound,  but  he  can  no  longer 
produce  an  articulate  sound.  Although 
he  understands  what  is  said  and  can 
think,  he  is  unable  to  give  expression  to 
his  thought;  it  may  be  possible  for  him 
to  pronounce  letters  or  even  meaning- 
less words, — he  may  even  retain  some 
words, — but  these  are  usually  interjec- 
tions of  some  kind.  In  some  cases,  nouns 
only  or  verbs  only  are  forgotten.  One 
language  may  be  forgotten  and  another 
remembered.  This  variety  of  aphasia  is 
usually  encountered  in  persons  who  are 
afEected  with  right  hemiplegia.  In  some, 
however,  who  are  left-handed,  there  may 
be  left  hemiplegia.  In  some  cases,  al- 
though speech  is  impossible,  the  patient 
can  articulate  in  singing,,  especially  if 
certain  well-known  airs  are  sung,  the 
words  in  that  case  having  become  inti- 
mately connected  with  the  notes. 

Case  of  aphasia  in  a  child  which, 
though  unable  to  utter  a  single  word 
as  regards  spontaneous  speech,  could 
articulate  in  singing.  Knoblauch  (.Jour, 
of  Nerv.  and  Mental  Dis.,  .June,  '92). 

Case  of  total  aphasia  of  articulation  in 
which  the  patient  Avas  able  to  intone  t'.ie 
voice  intelligently,  as  one  does  in  speech. 
No  agraphia;  woi'ds  readily  understood. 
Brissaud  (I.a  Semaine  Med.,  Aug.  1,  '94). 
Case  of  traumatic  aphasia  dependent 
upon  sun-stroke.  Three  attacks  have  oc- 
curred in  which  the  patient  became  un- 


APHASIA.     SYMPTOMS. 


435 


conscious,  and  was  paralyzed  in  the  right 
arm,  leg,  and  lower  part  of  the  face. 
While  recovering  consciousness  he  began 
to  speak  in  Norwegian:  a  language  that 
he  had  not  used  for  many  years.  Later 
his  language  was  a  conglomeration  of 
English  and  Norwegian.  Eventually  lie 
recovered  completely.  E.  Mackey  (Brit. 
Med.  Jour.,  Dec.  10,  '98). 

Aphasia  may  occur  in  iiraemia,  and  is 
at  times  the  sole  expression  of  that 
state.  It  is  frequently  associated  with 
right-sided  motor  paralysis,  hemiplegic 
or  monoplegic  in  character.  It  may  be 
the  precursor  of  urfemic  convulsions  or 
coma.  The  aphasia  is  usually  of  the 
motor  type,  but  it  may  be  sensory. 
There  may  be  word-blindness  and  word- 
deafness.  It  may  be  associated  with 
agraphia,  even  when  there  is  no  paralysis 
of  the  limbs.  It  is  comparatively'  fre- 
quent in  children,  particularly  in  eases 
of  post-scarlatinal  nephritis.  In  adults 
it  may  occur  in  any  form  of  Bright's 
disease.  It  is  generally  transient,  dis- 
appearing completely.  In  time  it  is  in- 
termittent and  has  a  marked  tendency 
to  recur.  When  paralysis  is  present  the 
two  may  disappear  simultaneously, 
usually  the  aphasia  first.  The  features 
of  ursemic  aphasia  are,  per  se,  not  char- 
acteristic of  the  causal  condition.  The 
most  important  diagnostic  features  are 
the  transitoriness  of  the  aphasia  and 
the  presence  of  other  ursemic  symptoms 
and  of  signs  of  nephritis.  In  every  case 
of  sudden  aphasia,  the  possibility  of  its 
being  renal  in  origin  should  be  consid- 
ered, and  careful  studies  of  the  urine 
and  of  the  system  at  large  should  be 
made  with  this  thought  m  mind.  D. 
Kiesman   (Med.  Record,  .June  14,  1902). 

Ageaphia. — Agraphia  consists  in  the 
loss  of  the  memory  of  the  necessary  move- 
ments to  write.  In  an  uncomplicated 
case  the  patient  is  able  to  speak,  hear,  or 
read  as  usual,  but  when  he  tries  to  write 
he  finds  that  he  can  no  longer  do  so, 
though  he  is  capable  of  copying  letters 
or  designs  placed  before  him.  Pure 
agraphia  is  uncommon.  It  is  usually 
associated  with  some  degree  of  aphemia. 


Agraphia  can  only  occur  in  those 
persons  whose  education  is  sufficiently 
advanced  to  enable  them  to  write  auto- 
matically. 

In  a  thesis  written  under  the  direction 
of  Dejerine  the  following  conclusions 
reached: — 

The  centi'cs  of  the  images  of  language 
(motor  centres  for  articulation  and  visual 
and  auditory  centres)  are  grouped  in 
the  convolution  about  the  fissure  of 
Sylvius,  forming  the  zone  of  language. 

Any  lesion  of  this  zore  g.ves  rise  to  an 
altei-ation  in  the  inter-.or  language  and 
consequently  to  manifest  or  latent  alter- 
ations throughout  all  the  modalities  of 
language  (speech,  hearing,  writing)  with 
special  predominance  over  the  function  of 
the  directly  destroyed  images.  Agraphia 
is  always  present.  These  form  the  class 
of  true  aphasias. 

The  class  of  pure  aphasias  (motor, 
subcortical  aphasia,  pure  word-blindness 
of  Dejerine,  pure  word-blindness)  are 
located  outside  the  zone  of  language  and 
leave  untouched  the  inner  language. 
Thej'  never  cause  agraphia  and  afl^eet 
only  one  of  the  modalities  of  language. 
They  form  a  group  apart  from  the  true 
aphasias.  Nothing  would  tend  to  show 
the  existence  of  a  motor  centre  for 
graphic  images.  Both  clinical  observa- 
tion and  pathological  anatomy  agree  as 
to  its  absence. 

The  existence  of  pure  agraphia  has  not 
yet  been  established.  Mirallig  (Revue 
des  Sei.  MSd.  en  France  et  il  I'Etranger, 
July  15,  '96). 

Amimia. — Sign-language,  as  practiced 
by  deaf-mutes  in  gestures  and  panto- 
mimic speech  generally,  may  be  affected 
by  a  cerebral  lesion.  Loss  of  pantomimic 
speech  is  often  co-existent  with  aphemia 
or  agraphia  or  both.  It  is  rarely  or  ever 
found  alone,  although  it  is  quite  possible 
to  conceive  of  its  separate  existence  in 
one  in  whom  this  faculty  had  been  espe- 
cially cultivated.    (Mills.) 

Sensoet  Aphasia. — Auditory  Apha- 
sia.— This  variety  is  more  rarely  met 
with  than  motor  aphasia.     Both  the  re- 


436 


APHASIA.    SYMPTOMS. 


ceptioD  and  production  of  audible  speech 
are  deficient,  the  leading  symptoms  be- 
ing, on  the  receptive  side,  word-deafness 
and,  on  the  productive  side,  word-am- 
nesia and  articulative  amnesia. 

Speech  and  separate  words  are  dis- 
tinctly heard  by  the  subject,  but  no 
meaning  is  attached  to  them.  Sounds, 
however, — such  as  that  of  an  engine- 
whistle,  an  alarm-clock,  the  hour, — are 
heard  and  recognized.  Eight  hemiplegia 
and  a  certain  amount  of  word-blindness 
are  frequently  present.  Certain  cases  of 
auditory  aphasia  hear  as  if  spoken  to  in 
a  foreign  tongue,  but  they  cannot  under- 
stand what  is  said,  although  they  en- 
deavor to  do  so.  Other  patients  under- 
stand neither  what  is  said  to  them  nor 
what  they  themselves  say,  but  can  repeat 
words  after  another.  They  repeat  like 
parrots  (echolalia)  what  is  said;  but,  if 
the  centre  of  articulate  voice  is  still  par- 
tially connected  with  the  sensory  centres 
of  audition  and  the  latter  are  normal,  the 
repetition  of  the  word  may  suddenly  give 
rise,  in  their  mind,  to  the  idea  conveyed 
by  the  word.  Instead  of  articulate  speech 
the  phenomena  may  show  themselves  in 
connection  with  music  or  numbers.  In 
subcortical  word-deafness  the  patient 
hears,  but  does  not  imderstand.  He  can, 
however,  repeat  at  once  whatever  he 
hears,  and  write  it  down.  While  writing 
or  speaking  he  may  understand  the  words 
used,  but  not  after  the  mechanical  act  is 
accomplished. 

Case  of  woman,  aged  72  years,  who 
had  been  deaf  since  childhood,  and  re- 
mained so  until  within  six  weeks  of  an 
apoplectic  attack.  Hearing  during  this 
period  of  six  weeks  had  returned  and 
remained.  After  the  apoplexy  she  was 
found  to  be  absolutely  word-deaf.  There 
were  also  motor  aphasia  and  agraphia, 
with  word-blindness.  Shaw  (Brit.  Med. 
Jour.,  Feb.  27,  '92). 

[This  case  presents  several  features  of 
interest,  among  which  may  be  noticed 


the  return  of  hearing  six  weeks  before 
the  last  stroke,  to  disappear  again  on  its 
supervention;  the  remarkable  picking 
out  by  the  lesions  of  the  several  cortical 
areas,  which  by  various  observers  have 
been  associated  with  the  faculty  of  lan- 
guage corresponding  with  the  clinical 
phenomena  recorded, — the  second  frontal 
convolution  with  the  agraphia,  the  third 
frontal  with  the  aphasia,  the  angular 
gyrus  with  the  word-blindness,  the  tem- 
poro-sphenoidal  with  the  word-deafness 
and  general  deafness, — and  the  apparent 
recognition  by  the  patient  of  the  total 
failure  to  make  herself  understood,  this 
last  feature  being  somewhat  noteworthy 
in  view  of  the  extensive  nature  of  the 
cortical  lesion.  L.  C.  Gray  and  W.  B. 
Pkitchard,  Assoc.  Eds.,  Annual,  '93.] 

Medico-legal  conclusions  drawn  from  a 
consideration  of  aphasia:  — 

1.  Organic  diseases  of  the  brain  may 
render  a  patient  incapable  of  making  a 
will,  and  that  some  form  of  aphasia  may 
be  produced  also  as  one  of  the  symptoms 
of  the  organic  disease. 

2.  Some  forms  of  aphasia  may  render 
a  patient  incapable  of  will-making. 

3.  Auditory  aphasia,  if  at  all  well 
marked,  incapacitates  a  patient  from 
will-making. 

4.  Some  other  forms  of  aphasia,  such 
as  pictorial  word-blindness,  pictorial  mo- 
tor aphasia,  and  graphic  aphasia,  may 
render  a  patient  incapable  of  making  a 
will,  not  necessarily  from  being  mentally 
incapable,  but  from  the  difficulty  of 
carrying  out  the  legal  formalities. 

5.  These  difficulties  in  carrying  out  the 
legal  formalities  necessarily  vary  accord- 
ing to  the  law  of  the  particular  country. 

6.  Simple  uncomplicated  eases  of  infra- 
pictorial  auditory,  infrapictorial  visual, 
and  infrapictorial  motor  aphasia  are 
capable  of  valid  will-making.  William 
Elder  (Brit.  Med.  Jour.,  Sept.  3,  '98). 

Case  in  which  the  patient,  during  the 
year  preceding  death,  had  nrunerous  at- 
tacks of  transient  sensory  aphasia.  In 
the  intervals  there  was  no  paraphasia, 
the  language  being  correct,  but  he  did 
not  understand  what  was  said  to  him. 
At  autopsy  general  atrophy  of  the 
brain,  with  reduction  of  the  size  of  the 
superior    temporal    convolutions,    espe- 


APHASIA.    DIAGNOSIS. 


437 


cially  marked  on  the  left  side;  also  of 
the  operculum  and  of  the  inferior  fron- 
tal convolution.  The  ea.se  demonstrates 
that  word-deafness  is  essentially  of  cor- 
tical origin.  0.  Veraguth  (Deutsche 
Zeits.  f.  Nervenheilk.,  B.  xvii,  H.  2  and 
4,  1901). 

Word-blindness  (Alexia). — The  patient 
sees  written  or  printed  letters  and  words 
and  may  be  able  to  distinguish  one  from 
another,  but  they  no  longer  have  any 
meaning  for  him.  Word-blindness  is 
rarely  total,  however,  a  few  words  or  let- 
ters being  usually  understood,  nor  is  the 
disorder  often  found  existing  alone.  In 
nearly  every  case  there  co-exists  either 
word-deafness  or  motor  aphasia  or  some 
other  complication  of  speech. 

Word-blindness  is  often  found  in  con- 
nection with  right  lateral  hemianopsia, 
or  concentric  diminution  of  the  field  of 
vision.  The  patient  can  no  longer  read, 
but  can  write;  as  he  cannot  read  what 
he  has  written  the  letters  and  lines  are 
sometimes  uneven  and  resemble  those 
written  with  the  eyes  shiit.  In  the  right 
hemianopsia  found  in  this  connection 
the  written  lines  always  begin  on  the  left 
side  of  the  page.  The  visual  memory  of 
numbers  may  be  preserved  or  may  also 
be  lost  (coscitas  numeralis).  Word-blind- 
ness can,  therefore,  he  divided  into  two 
categories:  in  the  one,  the  sense  of  the 
letter  itself  is  lost  (ccecitas  literatis);  as 
a  consequence,  persons  who  generally 
read  slowly,  and  spell  out  each  word, 
suffer  the  total  loss  of  the  power  of  read- 
ing. In  the  other,  the  accompanying 
hemianopsia  prevents  the  general  phys- 
iognomy of  a  word  being  rapidly  taken 
in  by  the  patient  (cwcitas  verbalis). 

Subcortical  Word-blindness.  —  In  sub- 
cortical alexia  the  patient  can  read  or 
copy,  but  he  does  not  understand  what 
he  does  until  the  movement  of  his  hand 
awakens  in  his  mind  the  sense  of  word- 


hearing  and  of  motor  articulation  through 
the  muscular  sense. 

In  piTre  verbal  blindness  the  meaning 
of  the  words  may  be  lost,  but,  by  follow- 
ing with  the  eye  the  form  of  the  letters, 
the  patient  finally  may  spell  out  the 
word. 

Four    cases    of   word-blindness.      The 
first  occurred  in  a  man  34  years  of  age. 
In    this    case    the    condition    developed 
after  an  attack  of  left  hemiplegia  with 
paralysis   of  the   left   side  of  the   face, 
from  which  he  had  been  recovering  grad- 
ually.    The  second  case   occurred  in   a 
man    57    years    of   age.     The    condition 
came   on  very  suddenly    during    active 
exercises.     It  was  ushered  in  by  slight 
frontal  headache  and  some  mental  con- 
fusion.    The   third   case   occurred   in   a 
man    60   years    of   age.      The    onset    in 
this  case  was  also  abrupt.     The  fourth 
case  occurred  in  a  woman  34  years  of 
age.    In  this  case  the  onset  was  marked 
by  unconsciousness,  which  remained  for 
several   days.     Then  consciousness   was 
restored,  paralysis  in  the  right  arm  and 
right  leg  developed,  and  she  was  com- 
pletely aphasic.      J.  Hinshelwood   {Lan- 
cet, Feb.  8,  1902). 
Apeaxia.  —  In    apraxia    (Kussmaul) 
the  patient  no  longer  recognizes  the  use 
of  objects  which  he  sees;   a  fork  to  him 
convej's  no  meaning  of  its  use.    Apraxia 
may  affect  other  senses  besides  that  of 
sight, — as,  for  example,  hearing,  taste, 
smell,  etc., — the  sound  of  a  bell  may  no 
longer  conTey  a  meaning  or  the  taste  of 
a  dish. 

Diagnosis.  —  In  all  cases  of  actual  or 
suspected  aphasia  the  patient  should  be 
examined  as  to  his  ability:     1.  {a)  To 
speak  voluntarily;    (&)  to  speak  clearly 
and    distinctly,    pronouncing    properly; 
(c)  to  repeat  words  dictated  aloud.     2. 
{a)  To  write  voluntarily  letters,  words. 
Additional   form    of   visual   defect   in 
which  there  is  not  only  word-blindness, 
but  also  failure  to  recognize  the  indi- 
vidual  letters   of   words.     Hinshelwood 
(Lancet,  Dec.  21,  '9.5). 


438 


APHASIA.     ETIOLOGY. 


numerals,  and  sentences;  (&)  to  write 
from  dictation;  (c)  to  copy;  {d)  to 
understand  what  he  has  written.  3.  (a) 
To  vinderstand  words  and  sentences 
spoken;  (i)  to  understand  or  recognize 
vocal  and  instrumental  music;  (c)  to 
understand  the  use  of  objects  named. 
4.  (a)  To  read  words,  letters,  numerals, 
and  musical  symbols  if  previously  famil- 
iar with  them;  (&)  to  call  objects  by 
their  names;  (c)  to  recognize  the  use  of 
objects  exhibited;  (d)  to  read  and  com- 
hend  what  is  read.  5.  (a)  To  name  and 
recognize  the  use  of  objects  felt,  tasted, 
or  smelt. 

WOED-DEAFNESS  must  be  distinguished 
from  deafness.  If  the  patient  does  not 
suffer  from  aphemia,  it  will  be  at  once 
perceived,  from  his  ability  to  hear  simple 
meaningless  sounds,  that  he  is  not  sim- 
ply deaf.  When  word-deafness  exists  in 
combination  with  aphemia  and  word- 
blindness  (this  latter  complication  is  un- 
common) the  diagnosis  must  be  made 
between  true  word-deafness  and  apparent 
deafness  with  dumbness  in  a  non-hemi- 
plegic,  demented  subject. 

If,  however,  the  symptoms  have  fol- 
lowed an  apoplectic  stroke  with  right 
hemiplegia,  the  affection  is  probably 
word-deafness  due  to  a  cortical  lesion. 

WoED-BLiNDNESS,  if  isolated,  is  easily 
recognized. 

Aphasia,  ok  Aphemia. — Aphasia 
should  be  diagnosticated  from  (1)  mutism 
due  to  melancholia;  (2)  miitism  due  to 
hysteria;  (3)  the  silence  observed  in  hemi- 
plegic  patients  who  speak  with  difficulty; 
(4)  the  silence  observed  in  hemiplegia 
patients  who  are  suffering  from  pseudo- 
bulbar paralysis  of  cerebral  origin;  (5) 
word-blindness  associated  with  word- 
deafness.  All  these  present  individual 
characters  which  must  be  studied  in  con- 
nection with  the  general  symptomatology 
of  each  affection. 


Agraphia  arising  from  a  lesion  of  the 
centre  of  writing  should  be  distinguished 
from  (1)  the  inability  to  write  due  to 
hemiplegia  and  (2)  the  agraphia  due  to 
a  lesion  of  the  visual  centre  in  patients 
of  limited  education  and  who  copy  visual 
images;  (3)  the  agraphia  due  to  a  lesion 
of  the  auditory  centre,  in  which  the 
patient  writes  only  what  is  mentally 
heard  by  him. 

The  co-existence  of  word-blindness  or 
of  word-deafness  with  agraphia  should 
suggest  that  the  latter  might  be  due  to 
a  lesion  of  the  sensory  centres  (visual  or 
auditory),  especially  if  the  patient  did 
not  previously  write  automatically,  for 
agraphia  due  to  a  pure  lesion  can  arise 
only  in  cases  in  which  automatic  writing 
has  caused  the  development  of  a  special 
graphic  centre. 

Infeacoetical  Motor  Aphasia. — A 
pure  motor  aphasia  without  word-blind- 
ness or  word-deafness  is  likely  to  be 
of  infracortical  origin.  Cases,  however, 
have  been  reported  in  which  an  infra- 
cortical  lesion  has  caused  aphasia,  word- 
blindness,  and  word-deafness. 

Etiology.  —  The  various  varieties  of 
aphasia  occur  almost  always  as  a  mani- 
festation of  cerebral  lesion.  The  most 
common  factor  is  softening;  next  in 
frequency  are  cerebral  tumors  and,  es- 
pecially, syphilitic  lesions  (Fournier), 
cerebral  haemorrhage,  traumatisms,  and 
meningo-encephalitis. 

Aphasia  may  present  itself  during 
enteric  fever,  small-pox,  and  puerperal 
fever.  Transient  aphasia  —  following 
epileptic  or  hysterical  convulsions,  mi- 
graine, or  concussion  of  the  brain — has 
been  occasionally  observed,  and  certain 
degrees  of  the  affection  may  be  tempo- 
rarily present  and  even  recurrent  in 
states  of  profound  ansemia  of  the  cer-j- 
brum. 


APHASIA.     ETIOLOGY. 


439 


Case  of  mixed  aphasia  with  right  hemi- 
plegia due  to  meningo-encephalitis  from 
cysticercus,  affecting  principally  the  an- 
terior extremity  of  the  sphenoidal  lobe. 
Bitot  (Jour,  de  M6d.  de  Bordeaux,  Dec. 
15,  '89). 

Two  cases  dependent  upon  tubercular 
meningitis.  Picot  (Gaz.  Heb.  des  Sci. 
M6d.  de  Bordeaux,  Mar.  16,  Apr.  13,  27, 
May  11,  '90). 

Case  of  mixed  motor  and  sensory 
aphasia  consequent  on  influenza.  Re- 
covery after  several  weeks.  T.  D.  Poole 
(Edinburgh  Med.  Jour.,  Aug.,  '90). 

Case  of  motor  aphasia  with  graphla 
and  dyslexia  in  conjunction  with  attacks 
of  petit  mal.  Eye-strain.  Improvement 
from  properly  adjusted  glasses.  Mueh- 
leek  (Univ.  Med.  Mag.,  June,  '91). 

Case  with  right  facial  paralysis  and 
right  Jacksonian  epilepsy  due  to  injury 
over  base  of  right  parietal.  Recovery  in 
few  w-eeks.  Symptoms  supposed  to  be 
due  to  contusion  of  left  centres,  from 
counter- stroke.  Ransohoff  (Cincinnati 
Lancet-Clinic,  Apr.  16,  '92). 

Case  in  girl,  aged  10,  due  to  embolism. 
Suckling  (Brit.  Med.  Jour.,  May  21,  '92). 

Four  cases  occurring  during  puerperal 
period,  sixteen  from  literature;  some- 
times hysterical;  in  others,  urfemic.  In 
nearly  one-half  of  the  cases  aphasia  is 
associated  with  right  hemiplegia  and  due 
to  embolism  or  thrombosis.  Having  oc- 
curred in  one  pregnancy,  it  is  liable  to 
occur  in  the  next,  and  usually  appears 
about  one  week  after  delivery.  Cowe 
(Archives  de  Tocol.  et  de  Gyn.,  vol.  xx, 
No.  7,  '94). 

Several  cases  of  ataxic  aphasia  during 
pneumonia.  In  every  case  there  was  pa- 
resis and  weakness  of  the  right  face  and 
right  arm.  Cause  supposed  to  be  pneu- 
mococcus  toxins.  Chantemesse  (Med. 
Record,  Feb.  3,  '95). 

Case  occurring  as  result  of  wound  in 
left  side  of  skull  9  centimetres  from  hori- 
zontal circumference,  passing  by  superior 
border  of  auditory  meatus  and  supra- 
orbital margins,  7  centimetres  from 
sagittal  ■  suture  perpendicularly,  1  '/j 
centimetres  in  front  of  left  auditory 
canal.  Spherical  fragment  separated  and 
pressed  down  1  centimetre  into  the 
wound.     As  soon  as  removed,  speech  be- 


came normal.    Dorrenberg  (Berliner  klin. 
Woch.,  No.  18,  '95). 

Case  of  a  woman,  aged  20  years,  who 
was  infected,  after  her  marriage,  with 
gonorrhea,  and  who  was  attacked  with 
severe  convulsive  movements  in  the  right 
side  of  the  face  and  tongue  and  in  the 
right  forearm.  The  following  morning 
there  were  present  right  hemiplegia  and 
complete  motor  aphasia.  Sensitiveness 
was  preserved.  The  hemiplegia  persisted 
and  typical  contracture  occurring,  but 
the  paralysis  of  the  facial  and  pharyngeal 
muscles  improved.  The  aphasia  im- 
proved slowly.  After  six  months  it  was 
found  that  understanding  of  words  was 
completely  restored,  that  both  writing 
and  print  could  be  read,  only  some 
mutilation  of  words  remained  after  a  cer- 
tain time.  Repetition  of  words  was  per- 
fect. The  left  hand  could  be  used  to 
write  grammatically  with  good  orthog- 
raphy. Since  the  patient  suffered  from 
salpingitis  due  to  gonorrhoea,  the  troubles 
described  are  undoubtedly  due  to  a 
thrombosis.  L.  Bruns  (Schmidt's  Jahr- 
bucher,  B.  250,  p.  236,  '96). 

In  polyglottic  patients  suffering  from 
aphasia  the  disturbances  in  speech  do  not 
always  affect  to  the  same  degree  all  the 
languages  spoken  by  the  patients. 

When  recovery  occurs,  it  does  so 
usually  systematically  and  progressively; 
the  language  that  first  returns  is  usually 
the  one  first  learned.  The  patient  begins 
by  understanding  before  being  able  to 
speak.  At  times,  however,  there  occurs 
an  arrest  in  the  process  of  recovery:  the 
patient  in  such  a  case  recovers  only  the 
ability  to  understand  and  then  to  speak 
the  language  usually  spoken  by  him,  or 
he  may  understand  one  or  several  lan- 
guages, but  be  unable  to  speak  them. 

In  such  cases  it  is  evident  that  there 
is  no  destruction  of  the  cortical  centres 
of  speech,  but  only  of  shock  to  their 
elements.  The  varying  intensity  of  such 
shock  explains  the  gradation  of  the 
symptoms  noted  in  the  patients  seen  by 
the  writer. 

Consequently  it  is  rot,  in  general, 
necessary  to  claim  the  existence  of 
multiple  centres  of  speech,  each  one 
peculiar  to  one  of  the  languages  success- 
fully learned  by  patients  speaking  sev- 


440 


APHASIA.    PATHOLOGY. 


eral  languages.  The  paper  is  based  on 
seven  observations.  A.  Pitres  (Rev.  de 
M6d.,  Nov.,  '95;  Revue  des  Sci.  Med., 
'96). 

Case  in  which  the  patient,  who  had 
been  under  almost  continuous  observa- 
tion for  eighteen  years,  was  almost  com- 
pletely aphasie.  At  the  autopsy  Broca's 
convolution  was  found  to  be  intact. 
Bastian  {Lancet,  Dec.  19,  '96). 

Case  of  motor  aphasia  at  the  begin- 
ning of  scarlatina,  in  a  girl  aged  3  'A 
years.  The  aphasia  appeared  on  the 
fourth  or  fifth  day  of  the  eruption;  this 
differs  from  the  usual  time  of  appear- 
ance, which  is  late:  i.e.,  about  the  time 
of  appearance  of  renal  symptoms,  it  be- 
ing a  symptom  of  uraemia.  The  speech- 
disturbance  disappeared  after  fifteen 
days.  Brasch  (Berliner  klin.  Woch.,  No. 
2,  S.  30,  '97). 

Case  in  which  the  symptoms  were 
word-deafness,  verbal  amnesia,  jargon 
paraphasia,  paralexia,  loss  of  compre- 
hension of  print,  and  agraphia,  with 
retention  of  ability  to  copy  Roman 
letters  into  script  and  with  no  visual 
defect  whatever.  The  impairment  of  all 
ways  of  using  language,  so  often  ob- 
served as  a  result  of  auditory  lesion,  due 
to  the  fact  that  the  auditory  centre  is 
normally  active  in  spontaneous  speech, 
reading,  and  writing,  as  well  as  in  the 
comprehension  of  speech.  H.  T.  Pershing 
(Boston  Med.  and  Surg.  Jour.,  Sept.  23, 
'97). 

Case  of  aphasia  with  frequent  attacks 
of  word-deafness  and  spasm  of  the  right 
side  of  the  tongue  and  face.    At  autopsy 
tumor  was  found  in  the  lower  part  of 
the    Rolandic    fissure    resting    upon   the 
first  temporal  convolution.     Philip  Zen- 
ner  (N.  Y.  Med.  Jour.,  Jan.  8,  '98). 
Pathology. — Motor  Aphasia. — Pure 
aphasia  of  articulation  is  due  to  a  lesion 
of  the  foot  of  the  third  left  frontal  con- 
volution (Broca's  convolution).     If  the 
lesion  affects  more  than  this  region,  other 
symptoms   are  present.     If  the   lesion 
occupy  but  a  portion  of  the  region,  the 
aphasia  may  be   partial   only:    for  in- 
stance, nouns  only  will  be  missing.    In 
persons  habitually  left-handed  a  lesion 


of  the  third  right  frontal  convolution 
may  produce  motor  aphasia.  In  persons 
who  are  ambidextrous  the  aphasia  is  of 
slighter  degree  and  is  more  transient. 
The  lesion  may  be  either  cortical  or  sub- 
cortical. As  a  rule,  in  the  subcortical 
cases  the  defect  is  rarely  complete. 

Case  in  4-year-old  child.  At  the  au- 
topsy several  tubercular  nodules  were 
found  in  brain,  one  being  at  the  base  of 
the  left  third  frontal  gyrus.  Mosny 
(Bull,  de  la  Soc.  Anat.,  Mar.,  '88). 

Case,  lasting  ten  years,  with  distinctly 
causative  subcortical  lesion.  Horizontal 
section  through  Broca's  convolution 
showed  at  its  base  an  old  focus  of  soft- 
ening, 1  centimetre  in  diameter  and  2 
centimetres  from  the  cortex;  1  centi- 
metre farther  back  was  a  second  focus. 
A  section  1  centimetre  above  the  first 
showed  an  ancient,  grayish  focus  in  the 
white  substance,  on  a  level  with  the 
anterior  half  of  the  base  of  the  third 
frontal,  independent  of  the  other  two 
and  on  a  plane  anterior  to  them. 

Second  case,  with  centre  of  softening 
in  the  white  substance  to  the  third  fron- 
tal, prolonged,  on  a  level  with  the  in- 
ferior extremity  of  the  Rolandic  fissure, 
into  the  foot  of  the  ascending  frontal 
convolution.  Dejerine  (La  Semaine  Med., 
Mar.  4,  '91). 

Case  of  complete  motor  aphasia  conse- 
quent on  fall.  Ability  to  use  right  hand 
to  write;  left  hemiplegia.  At  autopsy 
left  hemisphere  found  normal;  right 
hemisphere  injured.  The  man  had  never 
been  left-handed.  Luys  (La  Semaine 
Med.,  Mar.  19, '91). 

Case  of  motor  aphasia  (partial)  with 
agraphia  (complete),  alexia  (partial),  and 
occasionally  auditory  aphasia.  Right 
hemiplegia.  Vast  focus  of  softening  in 
the  left  hemisphere.  Motor  aphasia  ex- 
plained by  destruction  of  the  third  left 
frontal;  motor  agraphia  by  destruction 
of  white  matter  connecting  inferior  pa- 
rietal with  second  left  frontal;  partial 
auditory  aphasia  by  destructive  lesion 
involving  first  temporal  lobe.  Incom- 
plete alexia  due  to  destruction  of  inferior 
parietal  lobe.  Bernheim  (Revue  de  M6d., 
May  10,  '91). 


APHASIA.    PATHOLOGY. 


441 


Case  with  right  hemiplegia,  with  tem- 
porary conjugate  deviation  of  the  eyes, 
excited  by  attempts  to  converge  the  eyes 
strongly  toward  the  middle  line.  The 
autopsy  proved  this  to  be  due  to  irrita- 
tive implication,  without  destruction  of 
the  region  shown  experimentally  by  Fer- 
rier,  Horsley,  Beevor,  Shafer,  and  Mott 
to  be  related  as  a  centre  to  these  move- 
ments. Delepine  (Brit.  Med.  Jour.,  Sept. 
10,  '92). 

Case  of  pure  motor  aphasia,  with 
ability  to  read  and  write  down  thought 
fluently  with  the  left  hand,  due  to  ex- 
tensive softening,  principally  affecting 
the  left  frontal  convolutions,  extending 
deeply,  even  to  the  internal  capsule  in 
the  white  substance. 

Case  in  accord  with  the  statement  that 
ability  to  understand  words  might  be 
retained,  with  complete  involvement  of 
the  frontal  convolutions,  and  that  agra- 
phia does  notj  as  claimed  by  some, 
belong  to  Broca's  aphasia.  Kostenitsch 
(Centralb.  f.  klin.  Med.,  Mar.  31,  '94). 

Motor  speech-centre  capable  of  further 
subdivision  into  subareas  representing 
various  perversions  of  functions  which 
are  in  relation,  through  isolated  lesions, 
to  the  subtypes  of  motor  aphasia,  includ- 
ing the  ataxic  and  amnesic,  the  agraphie 
and  others.  Wylie  (Archives  Clin.  de. 
Bordeaux,  Oct.,  '93,  to  May,  '94). 

Sole  well-demonstrated  anatomical  lo- 
calization is  that  of  the  foot  of  the  left 
frontal  convolution.  Bernheim  (Le  Bull. 
MSd.,  Oct.,  '94). 

Case  of  Jacksonian  epilepsy  accom- 
panied by  motor  aphasia  without 
agraphia,  conclusively  proving  that  the 
former  may  exist  without  the  latter. 
There  is  too  great  a  tendency  to  regard 
language  as  a  special  and  isolated  phe- 
nomenon among  manifestations  of  nerv- 
ous centres.  Prevost  (Revue  Mgd.  de 
la  Suisse  Rom.,  June,  '95). 

Disturbances  in  fifteen  cases  of  cortical 
motor  aphasia  due  to  destruction  of 
Broca's  convolution  correspond  exactly 
to  the  description  given  by  Trousseau. 
Patients  read  as  badly  as  they  write.  It 
is  incorrect  to  maintain  that  they  pre- 
serve ability  to  read  mentally.  Dgjerine 
(Le  Bull.  M6d.,  July  10,  '95). 


Case  of  syphilitic  apoplexy,  right  hemi- 
plegia, motor  aphasia,  and  word-blindness 
without  blindness  for  words  or  objects. 
Visual  field  showed  no  contraction  or 
hemianopsia.  Lannois  (Le  Bull.  M6d., 
Sept.,  '95). 

Case  of  motor  aphasia  following  in- 
fluenza which  occurred  in  a  previously 
healthy  woman.  There  were  likewise 
present  paresis  of  the  right  arm,  and 
paralysis  of  the  left  vocal  cord.  Sensa- 
tion was  somewhat  diminished  on  the 
right  side  of  the  face  and  in  the  right 
arm.  The  patient  could  neither  speak, 
repeat,  nor  write  a  single  word,  but  could 
understand  everything  and  read  both 
Written  and  printed  words.  The  symp- 
toms were  traced  to  two  lesions:  1.  To 
ulcerative  laryngitis  with  peripheral 
paralysis  of  that  branch  of  the  inferior 
laryngeal  nerve  which  supplies- the  pos- 
terior cricoarytenoid  muscle.  2.  To  cere- 
bral htemorrhage  which  caused  the  apha- 
sia and  the  paralysis  of  the  face  and 
arm.  Kohan  and  Stembo  (Schmidt's 
Jahrbucher,  B.  250,  H.  33,  '96). 

Case  showing  that  associated  move- 
ments of  the  arm  and  hand,  which  are 
observed  in  certain  people  when  speak- 
ing, may  be  unusually  prominent  m 
pathological  conditions  of  the  speech- 
centres.  E.  Eemak  (Neurol.  Centralb., 
Jan.  15,  '97). 

Case  of  a  man  who,  since  his  childhood, 
had  practiced  the  deaf-and-dumb  lan- 
guage, employing  his  right  hand  almost 
exclusively.  After  the  occurrence  of  a 
cerebral  thrombosis,  he  was  entirely 
unable  to  communicate  with  this  hand, 
although  the  paresis  was  not  great. 
With  the  left  hand  he  still  expressed 
himself  without  difficulty.  Grasset 
(Med.  News,  Jan.  16,  '97). 

Case  sustaining  Pitres  and  Charcot's 
view  that  there  must  be  a  homologue 
of  the  motor  speech-centres,  viz.:  a  spe- 
cial graphic  centre  containing  the  mem- 
ories of  the  motions  required  for  the 
execution  of  written  characters.  Destruc- 
tion of  these  memories  causes  inability 
to  write  in  written  characters,  while 
writing  with  printed  characters  may  be 
possible  with  the  help  of  the  visual  let- 
ter- and  word-  memories.  This  centre  of 
the  graphic  memories  is,  however,  prob- 


443 


APHASIA.    PATHOLOGY. 


ably  situated  in  close  proximity  to  the 
arm-centre;  possibly  both  may  be  con- 
tained within  the  same  cortical  area. 
B.  Onuf  (Jour.  Nerv.  and  Mental  Dis., 
Feb.,  Mar.,  '97). 

There  are  four  centres  in  the  cerebral 
cortex  which  are  concerned  in  the  pro- 
duction of  spoken  and  written  language. 
Two  of  these,  in  the  posterior  parts  of 
the  cerebrum,  correspond  in  position  to 
the  visual  and  (as  far  as  is  known)  audi- 
tory centres,  and  are  of  the  ordinary  sen- 
sory type;  the  others,  in  the  second  and 
third  frontal  convolutions,  respectively, 
are  excitomotor  centres  for  writing  and 
speech.  There  is  a  system  of  commis- 
sures between  the  various  centres,  the 
value  of  which  is  exemplified  by  such 
actions  as  reading  aloud  and  writing 
from    dictation.      When    any    particular 


Diagram  showing  the  approximate  sites  of  the 
four  word-centres  and  their  commissures. 
{Bastion.) 

channel  is  blocked,  other  commissures 
may  take  on  the  work.  This  is  especially 
true  of  the  eallosal  fibres  connecting 
the  two  hemispheres.  Aphasia  depends 
either  upon  damage  to  one  or  other  of 
the  four  centres  in  the  dominant  hemi- 
sphere, or  upon  interruption  of  the  com- 
missures connecting  them.  Attention 
called  to  the  considerable  power  of  re- 
ciprocal substitution  possessed  by  the 
visual  and  auditory  word-centres  for  the 
production  of  speech  and  writing,  re- 
spectively, and  to  the  fact  that  in  all 
probability  both  auditory  word-centres — 
and  not,  as  formerly  believed,  the  left 
alone — are  accustomed  to  act  on  Broca's 
centre  in  the  production  of  speech.  H.  C. 
Bastian  (Lancet,  April  3,  May  1,  '97). 

Case      of      complete      word-blindness; 
right-sided    homonymous    lateral    hemi- 


anopsia; no  agraphia,  but  inability  to 
read  own  writing;  optical  aphasia; 
temporary  mind-blindness;  the  ability 
to  spell  correctly  completely  retained. 

Case  of  paralysis  of  the  right  hand 
and  arm;  aphasia;  very  marked  word- 
blindness  presenting  the  peculiarity  that 
the  patient  could  read  many  words  (com- 
binations of  letters)  while  he  was  abso- 
lutely unable  to  recognize  the  individual 
letters  of  which  they  were  composed, 
with  some  impairment  of  the  motor  side 
of  the  speech-mechanism;  partial  right- 
sided  homonymous  hemianopsia,  with 
some  peripheral  constriction  of  the  sound 
half  of  each  field. 

Case  of  word-blindness  in  a  patient 
who  had  never  learned  to  write;  con- 
striction of  the  fields  of  vision  chiefly 
toward  the  right;  no  obvious  word- 
deafness;  cardiac  and  renal  disease; 
death;  extensive  old  softening  in  the 
white  matter  of  the  left  occipital  lobe 
and  of  the  left  angular  gyrus,  and  the 
back  part  of  the  first  temporo-sphenoidal 
convolution. 

Case  of  word-blindness  and  agraphia; 
instead  of  reading  individual  letters  as 
letters,  the  patient  substituted  a  word 
commencing  with  the  letter  which  he 
could  not  read — "George"  for  "G," 
"nearly"  for  "n,"  etc. 

Case  of  sudden  cerebral  attack  after 
confinement;  absolute  deafness  to  all 
sound  for  sixteen  days;  temporary 
motor  aphasia  and  word-blindness ; 
absolute  word-deafness  for  four  weeks; 
rapid  recovery  from  the  motor  aphasia; 
partial  recovery  from  the  word-blind- 
ness; very  slow  and  imperfect  recovery 
from  the  word-deafness;  slight  para- 
phasia and  slight  paragraphia;  echo 
speech;  retention  of  the  power  of  writ- 
ing from  dictation  and  of  reading  aloud; 
no  hemianopsia;  redevelopment  of  acute 
cerebral  symptoms  (meningitis  or  cere- 
bri tis)  six  months  after  the  original 
attack;    hyperpyrexia;    death. 

Sudden  cerebral  seizure  due  to  embolic 
infarction  in  a  man  aged  25  years; 
temporary  loss  of  power  in  the  right  side 
of  face,  right  arm,  and  right  leg;  com- 
plete motor  vocal  aphasia;  some — but, 
comparatively  speaking,  much  less — 
agraphia;     no   word-deafness;     no   word- 


APHASIA.     PATHOLOGY. 


443 


blindness;  complete  recovery  of  the 
power  of  writing;  gradual,  but  slight, 
improvement  as  regards  vocal  speech; 
second  embolic  attack  four  months  after- 
ward; increased  paralysis  of  the  right 
side  of  the  face,  of  the  right  arm,  and  of 
the  right  leg;  no  increase  of  the  motor 
vocal  aphasia;  marked  increase  in  the 
agraphia;  some  word-blindness;  no 
word-deafness;  death  four  years  after 
the  original  seizure. 

Seven  out  of  twelve  cases  supporting 
the  view  that  the  right  hemisphere  must 
be  regarded  as  forming  an  active  part 
of  the  nervous  speech-mechanism;  in 
other  words,  that  the  so-called  speech- 
centres  and  speech-faculties  are  bilat- 
erally represented.  Byrom  Bramwell 
(Lancet,  Mar.  20,  27;  April  10,  17;  May 
8,  22,  '97). 

Advisability  of  enlarging  the  zone  of 
language,  as  given  by  Dgjerine,  so  as  to 
make  it  include  a  centre  for  concepts  in 
the  third  temporal  convolution,  and  pos- 
sibly  extending  over  more   of  the  mid- 
temporal    region,    and,    in    addition,    a 
graphic  motor  centre  in  the  caudal  por- 
tion  of  the   second  frontal   convolution. 
This   zone    of    language    unquestionably 
has  its  deepest  organization  and  highest 
development  in  the  region  encircling  the 
Sylvian  fissure,  for  here  is  situated  the 
auditory  centre,  out  of  which  the  others 
may  be  said  to  have  been  evolved,  and 
the  motor,  articulatory,  and  visual  cen- 
tres which   are  next   in   importance,   as 
they   have   been    next   in    development; 
but  it  must  also  include  those  portions 
of  the  brain  in  which  concepts  originate, 
and,  if  the  views  of  those  who  believe  in 
separate  graphic  motor  centres  are  cor- 
rect, also  those  parts  in  which  graphic 
motor  images  are  represented.     Charles 
K.  Mills   (Medical  News,  .June  5,  '97). 
Agraphia.  —  True    agraphia    almost 
always  occurs  as  a  result  of  a  lesion  of 
the  foot  of  the  second  left  frontal  convo- 
lution or  of  the  subcortical  fibres  there- 
from.   Agraphia  is  generally  found,  how- 
ever, associated  with  some  form  of  motor 
aphasia,  rarely  existing  alone. 

Case  of  a  woman^  who,  at  44,  had  an 
attack  of  right  hemiplegia  involving  the 
tongue.     She   lost   the   abilitv   to   write 


Series  of  perimeter  charts  in  a  case  of  complete 
agraphia  and  almost  complete  word-blind- 
ness, with  right-sided  bilateral  temporal 
hemianopsia.  (The  black  area  represents 
the  blind  parts  of  the  fields.)  Chart  1 
represents  the  fields  of  vision  on  Nov.  17th. 
Chart  2  represents  the  fields  of  vision  on 
Nov.  24th.  Chart  3  represents  the  fields  of 
vision  on  Dec.  1st.  Chart  4  represents  the 
fields  of  vision  on  Dec.  8th.  Chart  5  rep- 
resents the  fields  of  vision  on  Dec.  15th. 
(Byrom  Bramxcell.) 


444 


APHASIA.     PATHOLOGY. 


spontaneously  and  from  dictation,  but 
could  copy.  There  was  no  word-deafness 
nor  word-blindness.  When  55,  a  second 
attack  of  hemiplegia  occurred,  this  time 
of  the  left  side,  with  complete  loss  of 
speech.  A  third  and  fourth  attack  oc- 
curred six  years  later,  and  death  eight 
years  afterward,  at  the  age  of  69.  At 
the  necropsy  areas  of  softening  were 
found  in  the  left  hemisphere  (1)  at  the 
posterior  extremity  of  the  second  frontal 
and  (2)  in  the  middle  portion  of  the  sec- 
ond frontal  on  the  right  side;  (3)  at  the 
anterior  extremity  of  the  third  frontal 
and  posterior  portion  of  the  third  fron- 
tal, extending  into  the  ascending  frontal 
(4)  at  the  foot  of  the  ascending  fron- 
tal and  parietal  and  (5)  in  the  pos- 
terior portion  of  the  ascending  parietal. 
Two  additional  areas  of  softening  were 
found  at  the  base  of  the  right  hemi- 
sphere, but  these,  with  No.  3,  were  sup- 
posed to  have  given  rise  to  no  symptoms. 
Nos.  2  and  4  caused  symptoms  of  bulbar 
paralysis,  No.  5  the  left  hemiparesis, 
while  No.  1 — the  lesion  at  the  posterior 
portion  of  the  second  left  frontal — was 
considered  responsible  for  the  peculiar 
form  of  agi'aphia.  Charcot  and  Du- 
breuihl  (Annual,  '94). 

The  above  or  similar  eases  reported  do 
not  prove  that  the  centre  for  written 
language  lies  in  the  second  left  frontal. 
It  is  very  difficult  to  isolate  and  localize 
a  pure  motor  agraphia.  Against  the 
hypothetical  existence  of  a  centre  for 
writing  in  the  above  case  is  the  fact  that 
no  one  could  write  with  the  feet  as  well 
as  with  the  hands,  although  it  can  be 
conceived  that  a  higher  motor  centre  for 
writing  may  exist,  connected  with  the 
lower  centres  for  the  hand  and  foot 
either  of  which  may  govern  the  periph- 
eral mechanism  of  writing.  The  same 
type  of  agraphia  had  accompanied  motor 
aphasia  in  this  case,  in  cases  in  which 
the  lesion  was  of  Broca's  convolution. 
Dfejerine   (Annual,  '94). 

Case  of  a  man  of  26  who  had  been 
violently  pushed,  the  head  striking  for- 
cibly against  edge  of  a  dresser.  Injury 
was  over  right  parietal  eminence.  For 
two  or  three  days  afterward  showed  the 
ordinary  symptoms  of  concussion.  Later 
he  could  not  recognize  letters  or  figures, 


nor  name  most  things  at  sight,  though 
he  could  point  out  anything  named,  and, 
a  name  being  suggested,  he  repudiated 
the  wrong  one  on  every  occasion.  Spon- 
taneous writing  was  confined  to  his  own 
name,  which  he  wrote  quickly.  He 
could  neither  write  from  dictation  nor 
read  aloud.  He  could  copy,  but  could 
not  transfer  printed  into  written,  nor 
written  into  printed,  characters.  The 
field  of  vision  was  normal  in  both  eyes. 
No  hemianopsia  was  present.  Gradually 
the  patient  improved.  Not  until  the 
man  Avas  able  to  read  aloud  was  there 
any  sign  of  undeistanding  any  written 
question.  He  could  read  aloud  a  few 
combinations  of  figures,  such  as  100  and 
1897,  and  write  1897  down  in  well-formed 
figures,  but  he  could  not  recognize  indi- 
vidual figures  at  sight,  nor  put  them 
down  from  dictation.  This  suggests  the 
possibility  of  there  being  a  distinct  group 
of  cells  the  function  of  which  is  to  store 
combinations  of  figures  wliich  might  be 
called  the  visual  figure-combination- 
centre  as  distinct  from  the  visual  figure- 
centre.  Four  divisions  of  the  visual 
nerve-centre  might  be  made:  (a)  one  for 
letters;  (6)  one  for  numerals;  (c)  one 
for  words;  (d)  one  for  combinations  of 
figures.  One  would  naturally  expect 
only  two  subdivisions:  (a)  a  centre  for 
letters  and  numerals;  (h)  a  centre  for 
words  and  figure-combinations.  But 
Hinshelwood  has  noted  that  there  are 
cases  in  which  the  visual  memory  for 
letters  is  entirely  lost,  while  that  for 
figures  is  intact,  or  in  which  the  visual 
word-memory  only  was  affected.  C.  Mac- 
Vicar  (Scottish  Med.  Jour.,  Nov.,  '98). 

Sensoey  Aphasia.  —  Cortical  word- 
deafness  is  usually  caused  by  a  lession  of 
the  middle  or  posterior  portion  of  the 
first  and  second  left  temporal  convolu- 
tion, chiefly  the  first.  Auditory  speech 
is  not,  however,  so  exclusively  a  left- 
brain  function  as  is  motor  speech;  hence 
the  fact  of  incomplete  and  more  tran- 
sient types  of  speech-defect  from  uni- 
lateral lesions  of  this  region.  Lesions 
affectins:    the    subcortical    white    fibres 


APHASIA.     PATHOLOGY. 


445 


from  this  area  give  rise  to  the  subcortical 
type  of  word-deafness,  as  it  is  termed. 

Case  of  lesion  of  the  left  temporal  lobe 
in  a  left-handed  man  without  word- 
deafness.  Seppili  (Alienist  and  Neurolo- 
gist, Apr.,  '93). 

Case  of  lesion  cf  the  first,  second,  and 
third  right  temporal  lobes,  with  word- 
deafness.  Many  similar  cases  are  re- 
ported in  literature;  two  cases  of  lesion 
of  the  left  lobe  in  left-handed  persons, 
without  deafness,  and  thirty  cases  with 
Avord-deafness  from  lesions  of  the  left 
temporal  lobe  in  right-handed  persons. 
Scavano  (Revue  Inter,  de  Bibliographie, 
June  10,  '93J. 

Case  of  deaf-mutism,  in  an  adult,  due 
to  symmetrical  lesions  in  the  two  tem- 
poral lobes.  The  first  and  second  tem- 
poral convolutions  were  replaced  by 
cicatricial  tissue;  the  third  was  atrophied 
and  sclerosed.  Seppili  (Alienist  and 
Neurologist,  Apr.,  '95). 

Three  autopsies  in  patients  with   sen- 
sory aphasia.    There  were  softening  and 
atrophy   of  the  left  first  temporal   con- 
volution.     Case    of    subcortical    aphasia 
noted.    The  patient  could  not  speak  and 
had    no    comprehension    of    spoken    lan- 
guage.   He  had  right  hemiplegia.    Soften- 
ing of  the  external  capsule  and  lenticular 
muscles  was  found  at  autopsy.     W.  T. 
Worcester    (N.   Y.    Med.   Jour.,    Jan.   8, 
'98). 
Cortical  word-blindness  is  caused  by 
a  lesion  of  the  postero-inferior  portion 
of  the  second  left  parietal  convolution 
(angulo-occipital  region). 

Lesions  affecting  the  optic  radiations 
of  Gratiolet  cause  the  subcortical  variety 
of  alexia.  Interruptions  of  relations 
through  commissural  fibres  with  any  of 
the  associated  speech-areas  will,  of  course, 
result  in  one  of  the  mixed  forms  of 
aphasia  or  in  subcortical  alexia. 

Fifty  cases  of  sensory  aphasia  in  which 
Broca's  centre  was  not  found  diseased. 
In  all  some  form  of  sensory  aphasia  was 
present,  and  in  all  the  lesion  lay  in  the 
lower  posterior  third  of  the  brain.  The 
convolutions  were  found  affected  in  the 
following  order:     The  first  temporal   in 


38,  the  second  temporal  in  27,  the  in- 
ferior parietal  in  21,  the  angular  gyrus 
in  25,  the  supramarginal  gyrus  in  12, 
the  occipital  lobe  in  12.  Paraphasia  may 
be  caused  by  lesions  in  various  locations. 
Word-deafness  due  to  a  lesion  of  the 
first  and  second  temporal  convolutions, 
and  word-blindness  may  be  produced  by 
lesions  lying  in  the  region  of  the  inferior 
parietal  lobule,  or  extending  over,  an- 
teriorly from  it,  into  the  temporal  region, 
or,  posteriorly,  into  the  angular  gyrus 
and  occipital  lobe.  Failure  to  recognize 
a  word  heard  implies  destruction  of  the 
temporal  cortical  area;  failure  to  recall 
the  name  of  an  object  seen  implies  the 
destruction  of  the  temporo-oceipital  asso- 
ciation tract  in  the  subcortical  white 
matter. 

If  the  lesion  be  extensive  enough  to 
involve  the  cuneus,  or  deep  enough  to 
reach  the  visual  tract  to  the  cuneus  as  it 
passes  beneath  the  angular  gyrus  and 
convexity  of  the  occipital  lobe,  it  will 
produce  hemianopsia;  if  not,  actual 
blindness  may  not  accompany  psychical 
blindness.  In  either  case  it  is  found  that 
when  things  are  not  recognized  they  can- 
not be  named  when  seen.  The  visual 
memory-pictures  lie  in  the  angular  gyrus 
and  inferior  parietal  lobule.  M.  Allen 
Starr   (Brain,  July,  '89). 

Case  of  word-blindness  with  agraphia, 
due  to  a  spot  of  softening  as  large  as  a 
five-franc  piece,  occupying  the  whole  of 
the  inferior  parietal  lobe.  Neither  motor 
aphasia  nor  word-deafness  was  present. 
Serieux  (Bull,  de  la  Soe.  de  Med.  Men- 
tale  de  Belgique,  Mar.,  '92). 

Case  of  alexia,  agraphia,  amnesic 
aphasia,  and  word-deafness,  due  to  tumor 
in  the  occipital  lobe,  having  largely 
destroyed  the  subcortical  commissural 
fibres  in  the  angular  gyrus.  Weissen- 
burg  (Archives  de  Neurol.,  July,  '92). 

Case  of  pure  word-blindness  for  letters, 
words,  musical  signs,  Avith  retained 
ability  to  read  figures  and  calculate.  No 
word-deafness  nor  difficulty  in  articula- 
tion nor  any  impairment  of  motor  power 
or  sensation.  Four  years  later  sudden 
seizure  and  death.  For  two  days  before 
death  there  were  paraphasia  and  agra- 
phia resulting  from  the  seizure,  which 
was   found   at  the  autopsy  to  have  in- 


446 


APHASIA.     PROGNOSIS. 


volved  the  left  inferior  parietal  convolu- 
tion and  angular  gyrus.  Old  yellowiah 
areas  of  softening  with  atrophy  found  in 
the  lingual  and  fusiform  lobules,  the 
cuneus,  and  the  apex  of  the  occipital 
lobe;  secondary  degeneration  in  the 
splenium  of  the  corpus  callosum;  and 
pronounced  atrophy  in  the  optic  radia- 
tions. The  right  hemisphere  was  intact. 
Histologically,  lesion  least  pronounced 
at  level  of  lower  lip  of  calcarine  fissure 
and  especially  localized  in  the  fusiform 
and  lingual  lobules,  the  tapitum,  and  the 
radiations  of  Gratiolet,  and  the  inferior 
longitudinal  fasciculus  of  Burdach  were 
entirely  destroyed.  All  of  the  structures 
in  the  descending  branch  of  the  calcarine 
fissures  were  involved  in  tlie  softening. 
Conclusion  that  the  lower  portion  of  the 
inferior  longitudinal  fasciculus  of  Bur- 
dach contains  fibres  that  connect  the 
visual  centre  with  the  centre  for  lan- 
guage. Dejerine  and  Vialet  (Comptes 
Rendus  Heb.  des  Seances  et  Memoires  de 
la  Soc.  de  Biol.,  No.  28,  p.  790,  '93). 

Review  of  the  literature  of  sensory 
aphasia,  and  several  cases.  Conclusion 
that  the  essential  central  lesion  which 
produces  word-blindness  is  the  angular 
gyrus,  there  being  but  little  evidence 
tending  to  show  that  the  supramarginal 
gyrus  has  anything  to  do  with  this  phe- 
nomenon.   Shaw  (Brain,  Winter,  '93). 

Hemianopsia  and  word-blindness  are 
not  necessarily  associated.  The  frequent 
association  of  word-blindness  with  hemi- 
anopsia is  explained  by  the  intimate 
relations  existing  between  the  supra- 
marginal  convolution  and  the  bundle  of 
optic  radiations.  In  order  to  explain  the 
absence  of  word-blindness  in  right  lateral 
hemianopsia  it  is  necessary  to  call  at- 
tention to  the  intrahemispheric  fibres  of 
the  corpus  callosum;  these  latter  are 
injured  in  subcortical  alexia,  or  pure 
word-blindness.  In  order  to  obtain  word- 
blindness  without  hemianopsia,  there 
must  be  a  lesion  of  the  supramarginal 
convolution  superficial  enough  to  avoid 
injuring  the  underlying  white  fasciculi. 
Absence  of  hemianopsia  in  word-blind- 
ness or  total  aphasia  affords  a  much 
more  favorable  prognosis.  Joanny  Roux 
(Revue  des  Sci.  M6d.  en  Fi-ance  et  a 
I'Etranger,  Apr.  15,  '96). 


Prognosis.  —  Word-deafness  may  con- 
tinue permanently,  but  it  frequently  im- 
proves through  the  co-operation  of  other 
sensory  centres,  and  especially  the  visual 
centre.  The  patient,  noting  the  move- 
ments of  the  lips  in  those  who  are  speak- 
ing to  him,  recalls  motor  images  which 
articulation  of  the  same  words  would 
require  in  him. 

Word-blindness  does  not  improve  in 
some  cases;  in  others  a  painstaking  and 
early  re-education  may  be  carried  out 
by  which  new  images  may  be  created  in 
the  visual  memory  by  the  help  of  the 
motor  and  auditory  memories. 

Aphasia  proper,  or  aphemia,  occasion- 
ally remains  the  same  from  the  begin- 
ning to  the  end,  no  improvement  being 
visible;  usually,  however,  words  return 
very  gradually.  Eecovery,  in  such  cases, 
is  never  complete. 

Some  cases  recover  almost  immedi- 
ately. This  almost  always  occurs  in  eases 
of  complete  aphasia,  and  would  seem  to 
be  of  dynamic  origin,  like  the  mutism  of 
hysteria  or  of  terrified  persons. 

Case  with  agraphia,  but  without 
alexia,  of  eight  years'  standing.  During 
an  attack  of  anger  a  sudden  pain  was 
felt  in  the  headj  and  this  was  followed 
by  recovery  of  speech.  Dobie  (Lancet, 
Jan.  9,  '92). 

In  cortical  motor  aphasia  the  patient 
recovers  the  faculty  of  reading  gradually 
in  the  following  order:  (1)  appearance 
of  the  word;  (2)  association  of  syllables; 
(3)  association  of  letters  forming  each 
syllable.  Exact  reverse  of  learning  to 
read  during  childhood.  Thomas  and  J. 
C.  Roux  (Le  Bull.  Med.,  July  10,  '95). 

Systematic  recovery  occurs  in  cases  in 
which  the  centres  of  speech  are  shocked, 
but  not  destroyed,  by  cerebral  lesions 
which  cause  aphasia,  and  which  grad- 
ually resume  their  functional  activity. 
A.  Pitres  (Rev.  de  Med.,  Nov.  10,  '95). 

If  congenital  aphasia  is  found  in  a 
child  under  three  years,  especially  if  it 
be  rickety  or  hydrocephalic,  the  disorder 


APHASIA.     TREATMENT. 


447 


may  be  due  to  a  simple  retardation  of 
development;    if  the  patient  is  more  than 
three  years  old  the   prognosis   must  be 
very  guarded.     Herzen   (Revue  M6d.  de 
la  Suisse  Rom.,  Nov.  20,  '95). 
Agraphia  is,  in  some  cases,  recovered 
from,  in  the  sense  that  the  patient  learns 
to  write  with  the  left  hand.    The  writing 
does  not  resemble  that  performed  with 
the  right  hand,  and  in  some  cases  it  is 
written  from  right  to  left,  as  in  mirror- 
writing. 

Three    eases    treated    by    practice    in 
writing  with  the  left  hand;    centromotor, 
marked  improvement  in  a  few  months; 
centrosensory    aphasia    best    treated    by 
loud     speech     or     singing.       Gutzmann 
(Deutsche  med.-Zeit.,  Feb.  8,  '94). 
Supracortieal    motor    aphasia    is    less 
serious  than  cortical  motor  aphasia,  be- 
cause the  intelligence  is  less  affected,  the 
centre  of  language  itself  being  intact  and 
only  the  path  of  communication  being 
interrupted. 

Recovery  occurs  more  frequently  than 
in  cortical  motor  aphasia. 

The  prognosis  depends  on  the  site  and 
nature  of  the  lesion.  Incurable  lesions 
may  preclude  improvement  even  in  the 
slighter  eases  of  aphasia.  Extensive 
progressive  lesions  are,  of  course,  worse 
than  circumscribed  ones.  Haemorrhage, 
embolism,  thrombosis,  include  the  ma- 
jority of  cases  of  aphasia.  If  death  does 
not  occur,  even  the  worst  disturbances 
of  speech  may  be  recovered  from ;  while, 
on  the  other  hand,  even  slight  afleotions 
of  speech  may  persist  throughout  the 
remainder  of  life.  Age  is  an  important 
factor.  Children  may  learn  to  speak 
again  even  after  extensive  damage  to  the 
speech-centres,  whjreas  small  lesions  in 
old  people  may  produce  a  lasting  aphasia. 
The  individual  power  of  learning  un- 
doubtedly plays  a  part  in  the  result.  The 
longer  the  aphasia  has  lasted  without 
any  tendency  to  improvement,  the  worse 
the  prognosis,  and  this  is  also  the  case 
where  the  intelligence  steadily  fails. 
Karl  Bok  (Festschr.  des  Stuttgart.  Aerztl. 
Verein,  '97). 
Treatment. — When  there  is  no  paral- 


ysis present  mental  overwork  is  a  fre- 
quent cause  of  aphasia.  Prolonged  rest 
alone  secures  relief.  Any  disorder,  con- 
comitant or  causative,  that  may  be  pres- 
ent should  receive  careful  attention.  At 
the  same  time  the  patient  should  be 
taught  to  overcome  the  aphasic  symp- 
tom; considerable  patience  is  usually  re- 
quired. When  the  aphasia  is  associated 
with  right-sided  paralysis  or  convulsions, 
the  treatment  of  the  latter  condition  by 
alteratives,  potassium  iodide  or  mercury 
if  a  syphilitic  taint  be  present,  some- 
times brings  about  rapid  recovery. 

Case  combined  with  amimla,  the  result 
of  a  kick  of  a  horse  on  left  parietal 
bone.  Six  weeks  later,  on  examination, 
the  patient  was  found  without  fever, 
pulse  normal,  appetite  good,  eyes  and 
ears  normal,  and  no  paralysis,  except  of 
the  fingers  of  the  right  hand.  Over  left 
parietal  bone  were  three  ulcers,  the  low- 
est of  which  was  two  centimetres  over 
the  left  ear.  It  was  about  three  centi- 
metres long,  equally  wide,  bulged  out, 
and  showed  distinct  cerebral  pulsation. 
The  cranial  vault  was  depressed  about 
the  ulcers.  The  depressed  portions  of 
bone  were  removed,  the  corresponding 
defect  being  covered  «ith  two  flaps,  after 
von  Bergmann's  plastic  method.  The 
paralysis  of  the  hand  disappeared  rap- 
idly, followed  by  complete  restoration 
of  speech  on  the  twenty-second  day. 
Rosenberger  (Centralb.  f.  Chir.,  No.  25, 
'90). 

Remarkably  instructive  ease  of  nine 
years'  standing.  By  educating  the  right 
hemisphere,  within  six  weeks  acquire- 
ment of  a  vocabulary  of  over  one  hun- 
dred words  and  several  invaluable  short 
sentences.  Kucliler  (Priiger  med.  Woeh.,. 
Oct.  18,  '93), 

Case  cf  ursemio  aphasia.  The  patient, 
a  man  of  56,  was  suddenly  seized  with  an 
apoplectic  attack ;  he  regained  conscious- 
ness, but  presented  aphasia,  monoplegia 
of  the  right  arm,  and  a  systolic  murmur 
at  the  base  of  the  heart.  Some  days 
later  the  patient  was  seized  with  a  sud- 
den attack  of  intense  dyspncea,  with 
Cheyne-Stokes    respiration ;     the    urine 


448 


APHASIA. 


APIOL. 


was  scant  and  very  albuminous,  and 
the  blood  contained  seventy-five  centi- 
grammes of  urea  to  the  litre.  The  pa- 
tient was  bled  immediately  and  recov- 
ered in  two  days,  the  monoplegia  and 
the  aphasia  completely  disappearing. 
Eendu  (Gaz.  Med.  de  Paris,  Apr.  4,  '96). 
Case  of  complete  agraphia  and  almost 
complete  word-blindness,  with  right-sided 
bilateral  temporal  hemianopsia,  due  to 
a  lesion  (gumma)  in  the  region  of  the 
left  angular  gyrus,  in  which  rapid  and 
complete  disappearance  of  all  the  symp- 
toms took  place  under  the  administra- 
tion of  large  doses  of  iodide  of  potassium. 
Byrom  Bramwell  (Lancet,  Mar.  20,  '97). 
The  treatment  of  amnesic  aphasia  lies 
in  efforts  to  stimulate  the  defective  recol- 
lection of  words.  The  words  must  be 
learned  by  heart,  and  then  short  reading 
exercises  adopted.  The  exercises  should 
be  performed  in  front  of  a  mirror,  in 
order  to  restore  the  recollection  of  the 
necessary  movements.  In  motor  aphasia 
other  parts  of  the  brain  may  take  on 
function.  Single  sounds,  then  syllables, 
and  lastly  words  are  taught.  Writing 
exercises  with  the  left  hand  should  be 
performed  along  with  the  articulation 
exercises.  The  patient  should  be  taught 
to  form  words  from  printed  letters.  The 
treatment  of  sensory  aphasia  is  more 
diificult.  The  first  attempts  are  made  by 
means  of  written  language.  Lip-reading 
should  be  developed,  and  reading,  writ- 
ing, and  other  exercises  combined  with 
it.  The  ease  may  be  much  complicated 
by  a  combination  of  different  forms  of 
aphasia.  Much  patience  is  required. 
Karl  Bok  (Festschr.  des  Stuttgart. 
Aerztl.  Verein,  '97). 
Injury  to  the  skull,  especially  when 
there  is  depression  of  the  inner  plate, 
tumors,  cerebral  haemorrhage,  and  other 
conditions  capable  of  inducing  cerebral 
pressure  require  appropriate  surgical 
procedures. 

Case  combin-d  with  paraphasia  greatly 
benefited  by  trephining.  Fogliano  (Gaz. 
deg.  Osp.,  No.  4,  '91). 

Cases  illustrating  the  value  of  opera- 
tive measures:  — 

Case  of  mind-  and  word-  deafness  after 
repressed  fracture  of  the  skull  with  sub- 


cortical haemorrhage;  operation;  com- 
plete recovery. 

Case  of  glioma  of  the  left  centrum 
ovale,  monoplegia,  word-blindness,  alexia, 
agraphia,  partial  apraxia,  and  color- 
blindness;   operation;    improvement. 

Case  of  cyst  of  the  brain  in  the  foot 
of  the  left  second  frontal  convolution; 
motor  agi-aphia  (?)  from  inability  to 
spell;  evacuation  of  the  cyst;  improve- 
ment; traumatic  meningeal  htemorrhage 
two  months  later;  second  operation; 
recovery. 

Case  of  oro-lingual  paralysis  and  slight 
motor  disturbance  in  writing  of  throm- 
botic origin;    operation;    recovery. 

Case  of  motor  and  sensory  aphasia  of 
seven  years'  duration,  due  to  probable 
thrombosis  followed  by  angioma;  opera- 
tion; relief  of  pain;  slight  impi'ovement 
in  speech.  J.  T.,  Eskridge,  Clayton  Park- 
hill,  and  E.  J.  A.  Rogers  (Med.  News, 
June  20;  July  11;  Aug.  1,  15;  Sept. 
5,  '96). 

Landon  Caetee  Gray, 
Wm.  Beoaddus  Pkitchaed, 

New  York. 

APIOI.  —  Obtained  from  the  volatile 
oil  of  parsley,  and  at  low  temperatures, 
is  a  stearopten  or  eamphoraceous  solid 
made  up  of  needle-like  crystals;  but  at 
higher  temperatures  resolves  itself  into 
a  yellow  or  straw-colored  liquid.  It  has 
a  slightly-acid  reaction  and  is  soluble  in 
alcohol,  ether,  and  chloroform.  Most  of 
the  apiol  of  commerce  is  nothing  but  an 
oil  of  parsley,  though  the  best  has  usu- 
ally a  percentage  of  the  latter  added 
in  order  to  insure  fluidity  at  all  temper- 
atures. It  may  be  prepared  in  various 
ways,  but  the  methods  of  manufacturers 
as  published  are  usually  obscure,  and 
often  open  to  severe  criticism.  So-called 
green  apiol  is  the  oil  of  parsley  loaded 
with  chlorophyl  and  vegetable  fats.  The 
red  apiol  that  appears  in  the  market,  as 
well  as  the  proprietary  so-called  "apio- 
line,"  is  merely  the  yellow  apiol  oxidized 
by  means  of  sulphuric  acid. 


APOCYNUM  CANNABIXUM. 


449 


Dose. — Owing  to  unpleasant  odor  and 
acrid  taste,  apiol  is  best  administered  in 
gelatin  capsules  or  perles,  each  holding 
from  3  to  5  grains.  Two  to  four  capsules 
may  be  taken  daily,  preferably  night  and 
morning,  beginning  two  or  three  days 
before  the  expected  menstrual  flow. 

Physiological  Action.  —  Apiol  is 
thought  to  mainly  act  upon  the  vascular 
system,  causing  congestion,  and  at  the 
same  time  on  the  muscular  tissue  of  the 
uterus.  This  view  is  based  upon  its 
action  as  an  emmenagogue  and  by  its 
effects  upon  the  menstrual  flow;  yet  it 
is  also  a  regulator  of  uterine  function. 

Therapeutics.  —  According  to  Griifith 
and  Cerna,  apiol  (apioline)  may  be  re- 
garded as  the  best  emmenagogue  at 
present  known.  It  is  indicated  in  amen- 
orrhoea  due  to  ansemia  from  whatever 
cause.  W.  A.  ISTewman  Borland  believes, 
however,  that,  in  order  to  insure  the 
best  results,  it  should  be  combined  with 
some  preparation  of  iron;  he  also  sug- 
gests that  iron  be  given  uninterruptedly 
until  a  few  days  before  the  expected  ap- 
pearance of  the  menses.  Then,  continu- 
ing the  iron,  apiol  may  be  prescribed  in 
5-minim  doses,  two  or  three  times  a  day, 
until  the  appearance  of  the  menstrual 
■discharge. 

Apiol  (apioline)  strongly  recommended 
for  the  relief  of  dysmenorrhcea  and  amen- 
orrhoea.  Hill  (Virginia  Med.  Monthl/, 
Apr.,  '91);  Delmis  (Le  Prog.  M6d.,  Apr. 
25,  '91). 

In  the  treatment  of  dysmenorrhoeal 
cases,  where  there  is  no  tangible  pelvic 
lesion  demanding  strictly  local  attention, 
or  operative  interference,  I  have  of  late 
come  to  rely  on  a  single  remedy:  apiol, 
the  active  principle  of  Petroselinum 
sativum.  Three  illustrative  cases  of  the 
neurotic  variety  of  dysmenorrhcea,  dem- 
onstrating the  marked  value  of  the  drug 
as  a  therapeutic  agent,  D.  S.  Maddox 
(Med.  and  Surg.  Reporter,  .Tune  5,  '97). 

1- 


APOCODEINE.     See  Opiuji. 

APOCYNUM  CANNABINTJM.  —  This 

is  the  root  of  the  Apocynum  Canna- 
linum,  or  Canadian  hemp.  The  plant 
is  gray  or  brownish  gray  in  color,  with 
rather  thick  bark  and  porous  spongy 
wood.  It  contains,  besides  tannic  acid, 
gallic  acid,  and  gum  resin,  a  bitter  prin- 
ciple which  is  found  in  the  market  un- 
der the  name  of  "apocynin."  This  is 
an  amorphous  resinous  substance,  not  a 
glucoside,  easily  soluble  in  alcohol  and 
ether,  and  almost  insoluble  in  water. 

Apocynum  itself  is  inodorous,  and  has 
a  disagreeable,  bitter  taste. 

Dose.  —  The  powdered  root  may  be 
given  in  doses  varying  from  5  to  30 
grains.  In  small  doses  it  acts  as  a  bitter 
tonic;  in  10-  to  15-grain  doses  it  acts 
as  a  diaphoretic,  diuretic,  and  laxative. 
In  larger  doses — 15  to  30  grains — it  very 
considerably  irritates  the  gastro-intes- 
tinal  tract  and  gives  rise  to  vomiting  and 
diarrhoea. 

Dose  of  the  decoction  (1  drachm  to 
8  ounces),  1  y,  to  2  ounces  daily;  of  the 
tincture  (1  part  to  10),  5  to  10  minims. 
The  U.  S.  P.  fluid  extract,  in  doses  of 
from  10  to  30  minims,  is  a  valuable 
preparation. 

Physiological  Action. — Apocynum 
produces  a  very  pronounced  retardation 
of  the  pulse,  with  a  very  considerable 
enlargement  of  the  pulse-wave  and  a 
marked  rise  of  the  blood-tension.  The 
initial  retardation  of  the  heart  is  fol- 
lowed by  an  acceleration  of  the  cardiac 
action,  while  the  arterial  pressure  as- 
cends still  farther.  The  cardiac  retar- 
dation (first  stage)  is  caused  by  an  irri- 
tating action  of  the  drug,  both  on  the 
central  and  peripheral  inhibitory  appa- 
ratuses. The  subsequent  acceleration 
(second  stage)  is  not  dependent  upon 
anything  like  paralysis  of  the  inhibitory 


450 


APOCYNUM  CANNABINUM.    THERAPEUTICS. 


apparatus,  since  the  injection  of  another 
dose  of  the  infusion  can  again  give  rise 
to  a  retardation  of  the  heart's  work. 

On  the  injection  of  a  very  large  dose 
the  two  stages  are  followed  by  a  third 
one,  which  is  characterized  by  cardiac 
arhythmia,  the  appearance  of  Traube's 
waves,  and  a  gradual  fall  of  the  blood- 
pressure  down  to  0.  The  rise  of  the 
blood-tension  during  the  first  and  second 
stages  is  dependent  not  only  upon  the 
stimixlation  of  the  vasomotor  centres  in 
the  medulla  oblongata,  but  also  (and 
that  in  a  very  considerable  degree)  upon 
the  excitation  of  the  spinal  vasomotor 
centres.  Moreover,  the  heart  and  blood- 
vessels themselves  take  a  certain  active 
part  in  the  causation  of  the  rise.  Both 
the  central  and  peripheral  vasodilatory 
apparatuses  remain  wholly  intact.  (So- 
kalofE.) 

The  physiological  action  of  apocynum 
is  clinically:    To  strengthen  and  tone  up 
heart-action;    to  regulate  markedly  the 
irregular  heart — not  slowing  the  normal 
heart,  nor  increasing  the  blood-pressure, 
there  being  no  contraction  of  the  arteries. 
Its  diuretic  action   is  indirect   and   due 
to    its    "cardiokinetic"    effect,    and    not 
through    stimulation    of   the    renal    epi- 
thelium.    Decoctions  of  the  drug  cause 
mainly   catharsis   and   emesis.     Dose    of 
the  tincture  is  20  drops,  increased  to  30 
drops  thrice  daily.     T.  S.  Dabney  (Ther. 
Gaz.,  vol.  xxii,  p.   730,  '98). 
Therapeutics. — The  action  of  the  root 
of  the  Apocynum  Cannabinum  is  similar 
to  that  of  digitalis,  without  being  cumu- 
lative. 

Cardiac  Affections.  —  In  cases  of 
cardiac  dilatation  the  fluid  extract  rap- 
idly diminishes  the  area  of  dullness.  In 
cases  of  mitral  and  aortic  insufficiency, 
with  disturbed  compensation,  it  is  also 
valuable. 

The  action  of  the  root  of  Apocynum 
Camvabin'um  is  similar  to  that  of  digi- 
talis without  being  cumulative.  In  cases 
of   dilatation   the   fluid   extract   rapidly 


diminishes  the  area  of  dullness.  It  in- 
creases the  daily  amount  of  urine,  stops 
the  palpitation,  and  promotes  the  ab- 
sorption of  transudations.  With  the  ex- 
ception of  increased  pulsation  of  the 
arteries  of  the  head,  it  has  no  bad  sec- 
ondary effects.  A.  G.  Glinski  (Wratsch, 
'95). 

Seven  cases  of  mitral  and  aortic  in- 
sufSciency  with  disturbed  compensation 
in  which  the  fluid  extract  of  apocynum, 
15  drops  three  times  a  day,  was  used. 
Great  improvement  noticed  within  three 
days.  The  cardiac  impulse  grew  stronger, 
the  pulse  became  more  regular,  fuller, 
and  slower,  its  frequency  in  some  in- 
stances decreasing  from  130  or  120  to  56 
or  even  48  per  minute,  in  48  hours.  The 
blood-pressure  rose;  cyanosis  and  pulsa- 
tion of  the  cervical  vessels  vanished; 
the  area  of  cardiac  dullness  decreased; 
the  daily  quantity  of  urine  increased  (in 
one  case  it  rose  from  450  cubic  centi- 
metres to  2800  cubic  centimetres) ;  the 
body-weight  fell,  the  diminution  varying 
from  thirteen  to  twenty-one  Russian 
pounds.  No  unpleasant  accessory  effects 
from  the  drug  noticed.  Grozdinsky 
(Wratsch,  No.  19,  '96). 

Dropsy.  —  The  main  usefulness  of 
apocynum,  especially  when  the  fluid  ex- 
tract is  employed  in  doses  of  7  to  8  drops, 
is  in  the  treatment  of  dropsies.  Such  a 
dose,  repeated  at  short  intervals  if  nec- 
essary, causes  copious  watery  discharges 
from  the  bowels,  the  flow  of  urine  being 
increased.  As  tolerance  is  established  by 
continued  use,  it  is  necessary  to  increase 
the  dose  when  given  for  a  long  time. 
(Richmond.) 

It  is  also  possessed  of  diaphoretic- 
powers,  which  exert  an  effect  upon  the 
dropsy. 

Apocynum  properly  administered  is  a. 
very  remarkable  diuretic.  Doubtless  it 
acts  indirectly  by  increasing  the  arterial 
pressure,  but  it  must  also  be  a  direct 
renal  stimulant,  and  cause  dilatation  of 
the  renal  arterioles.  So  far  as  I  know, 
this  has  not  been  demonstrated,  but  the 
effects  point  to  such  a  mode  of  action. 
Its  influence  is  best  seen  in  those  general 


APOCYXUM  CANXABINUM. 


APOMORPHINE. 


451. 


efl'usions  that  depend  upon  a  want  of 
vascular  tone,  and,  whatever  the  reason, 
the  empirical  fact  remains  that  most 
remarkable  results  have  followed  its  use. 
A.  A.  Woodhull  (Brit.  Med.  Jour.,  Dec. 
11,  '97). 

Violent  catharsis  and  emesis  follow  its 
abuse  and  not  its  intelligent  use,  and  it 
is  a  really  trustworthy  and  singularly 
efficacious  hydragogue,  especially  in  ana- 
sarca. The  true  value  of  properly  admin- 
istered apocynum  is  as  a  diuretic.  It 
doubtless  acts  indirectly  by  increasing 
the  arterial  pressure,  but  it  must  also 
be  a  direct  renal  stimulant,  and  cause 
dilatation  of  the  renal  arterioles.  A.  A. 
Woodhull  (Brit.  Med.  Jour.,  Dec.  11, 
'97). 

To  assist  in  removing  the  solid  oedema 
which  often  prevents  the  healing  of  vari- 
cose ulcers  in  the  aged,  apocynum  has 
proved  more  useful  than  any  other  drug. 
F.  E.  Millard  (Med.  and  Surg.  Reporter, 
Apr.  16,  '98). 

Apocynum  is  excellent  in  cardiac 
dropsy  if  a  good  preparation  is  employed. 
Large  doses  are  apt  to  disagree,  and 
small  ones  are  preferable  for  diuretic  ac- 
tion. One  of  its  active  principles — apo- 
cynin — appears  to  resemble  digitalin  in 
its  effect  upon  the  heart;  so  that  the 
diuresis  produced  is  evidently  cardio- 
vascular in  character,  and  it  practically 
represents  the  diuretic  principle  of  the 
drug.  Apocynum  causes  no  cumulative 
effects,  and  it  will  occasionally  prove 
efficient  in  removing  dropsical  symptoms 
of  cardiac  insufficiency.  T.  B.  McGee 
(Amer.  Therapist,  No.  10,  1900). 

APOMOEPHINE.— Apomorphine  is  a 
pseudo-alkaloid  obtained  by  the  action 
of  HCl  on  morphine  in  sealed  tubes  at 
a  high  temperature.  The  base  can  be 
obtained  from  the  resulting  hydrochlo- 
rate  of  morphine  by  dissolving  in  water, 
adding  excess  of  bicarbonate  of  soda,  and 
extracting  by  means  of  ether  or  chloro- 
form. It  is  soluble  in  hot  or  cold  water 
and  in  alcohol.  In  powder  it  is  white; 
but  a  watery  solution,  though  at  first 
colorless,  soon  turns  black. 


The  salt  generally  employed,  however,. 
is  the  hydrochloride:  made  by  adding  a 
small  quantity  of  hydrochloric  acid  to  a 
solution  of  apomorphine.  It  occurs  in 
grayish-white  crystals,  which  are  odor- 
less and  slightly  bitter.  It  becomes 
green  on  exposure  to  light  and  air. 

Dose.  —  For  adults  Vis  to  Vo  grain. 
Great  care  must  be  observed  in  using  it 
in  feeble  persons.  Death  has  been  caused 
by  ^/i5  grain  under  such  circumstances. 
For  a  child  of  18  months,  ^/^^  grain;  2 
years,  Vm  grain;  3  years,  V35  grain; 
5  years,  V30  grain;  8  years,  ^/jj  grain. 
One-fifth  of  a  grain  should  not  be  sur- 
passed in  any  case  when  given  hypoder- 
micalljr,  and  ^/^  grain  when  administered 
by  the  mouth. 

The  drug  acts  with  more  rigor  in  some 
individuals  than  in  others.  Its  effects, 
therefore,  should  be  watched. 

Case  of  a  drunkard  in  whom  ^/lo  grain 
of  apomorphine,  hypodermically  admin- 
istered, followed  in  five  minutes  by  an- 
other ^Ao  grain,  caused  collapse,  uncon- 
sciousness, cold  surface,  and  absence  of 
pulse  at  the  wrist.  Westby  (Brit.  Med. 
Jour.,  Feb.  2,  '89). 

When  administered  on  an  empty 
stomach,  apomorphine  produces  vomit- 
ing much  more  readily  than  when  ad- 
ministered after  meals.  The  rate  of 
absorption  has  much  to  do  with  the 
entire  effect.  When  given  hypodermic- 
ally,  it  is  absorbed  at  once;  when  given 
on  an  empty  stomach,  it  is  absorbed 
more  rapidly  than  when  mixed  with 
foods.  Murrell  (Brit.  Med.  Jour.,  Feb. 
28,  '91). 

A  very  important  fact  is  the  great 
tendency  to  decomposition  shown  by 
apomorphine  hydrochloride  on  exposure 
to  moisture  or  moist  air.  As  it  is  also 
affected  by  light,  it  should  always  be 
kept  in  amber-colored  bottles.  Again, 
it  should  never  be  kept  in  solution,  the 
latter  being  always  made  fresh  when  it 
is  to  be  used.     Serious  symptoms  have 


452 


APOMORPHINE.    PHYSIOLOGICAL  ACTION.    POISONING.    THEKAPEUTICS. 


followed  neglect  to  heed  this  precau- 
tionary measure. 

Its  purity  may  be  tested  by  shaking 
up  in  a  test-tube  a  1-per-cent.  solution. 
If  the  latter  turns  emerald-green,  it 
should  not  be  employed.    (U.  S.  P.) 

Physiological  Action.  —  The  physio- 
logical action  of  apomorphine  as  an 
emetic  may  be  gathered  from  its  symp- 
tomatology, which  is  as  follows:  The 
administration  of  Vio  grain  hypoder- 
mically  is  followed  in  scarcely  one-half 
minute  by  fullness  of  the  head;  the 
pulse  is  quickened  and  increased  in  vol- 
ume; the  pupils  slowly  dilate;  the  face 
is  flushed.  Perspiration  soon  appears; 
the  respiration  become  more  frequent 
and  the  heart-beats  more  rapid;  and 
before  two  minutes  elapse  emesis  is  pro- 
duced. Then  comes  the  reaction,  a  gen- 
eral relaxation,  lasting  about  an  hour. 
The  eyes  are  sunken,  the  pupils  are 
widely  dilated,  and  the  face  is  pallid 
and  drawn.  Yawning  inaugurates  the 
period  of  recovery;  sleep  follows  and 
upon  awakening  all  effects  have  passed 
away.     (W.  D.  Carter.) 

These  effects  indicate  that  the  physio- 
logical action  of  apomorphine  must  be 
multiple.  This  has  been  found  to  be 
the  case  in  experiments  upon  animals. 
The  drug  seems  first  to  excite  the  cere- 
bral centres,  then  to  depress  them.  The 
peripheral  arteries  become  prominent 
and  tense,  indicating  arterial  tension, 
due  to  increased  rapidity  and  force  of 
cardiac  action. 

It  is  primarily  a  stimulant  and  finally 
a  paralyzant.  In  excessive  doses  it  causes 
convulsions,  but  in  a  manner  not  yet 
fully  understood. 

Therapeutic  doses  have  no  appreciable 
effect  aside  from  acceleration  of  the  pulse- 
rate,  the  maximum  being  reached  about 
the  time  vomiting  begins.  This  is  due  to 
stimulation  of  the  accelerator  mechan- 


ism. Following  vomiting  the  pulse-rate 
decreases:  the  probable  result  of  depres- 
sion of  the  heart-muscle,  since  it  has  been 
shown  that  apomorphine  is  a  muscle- 
poison. 

The  respirations  are  usually  increased, 
though  variably  so,  after  decided  doses. 
In  case  of  lethal  dose  respirations  cease 
as  a  result  of  paralysis  of  the  controlling 
centres. 

Apomorphine  has  very  slight,  if  any, 
influence  upon  temperature. 

Apomorphine  Poisoning. — When  poi- 
sonous doses  are  given  to  animals,  the 
opposite  of  the  above  is  the  case;  de- 
pression of  cardiac  action  first  occurs, 
followed  by  weakness  and  rapid  pulse. 

The  drug  also  acts  as  a  eonvulsant 
through  its  influence  upon  the  spinal 
cord,  the  convulsions  being  accompanied 
or  followed  by  muscular  paralysis.  The 
respiratory  centres  are  also  deeply  in- 
volved and  death  occiirs  from  respiratory 
paralysis. 

In  the  human  being  toxic  doses  of 
apomorphine  produce  collapse,  uncon- 
sciousness, failing  circulation  and  respi- 
ration, and  all  the  symptoms  of  profound 
depression  of  the  vital  centres.  Convul- 
sions usually  precede  the  profound  de- 
pression, and  vomiting  rarely  occurs. 
'  Treatmmt  of  Poisoning.  —  The  anti- 
dotes are  strychnine,  chloral,  and  chloro- 
form. These  should  be  supplemented 
by  the  more  diffusible  stimulants,  as 
ammonia,  whiskj'',  coffee,  etc.,  together 
with  external  heat. 

Therapeutics. — Apomorphine  is  doubt- 
less the  most  reliable  of  our  emetics  and 
the  one  which  acts  most  rapidly,  but  the 
effects  obtained  depend  greatly  upon  the 
quality  of  the  drug  used.  Untoward  ef- 
fects of  various  kinds  have  been  reported, 
including,  besides  those  added  to  the 
normal  action  of  apomorphine,  marked 
depression.     This  latter  has  occasioned 


APOMORPHINE.  THERAPEUTICS. 


453 


a  certain  amoimt  of  distrust  on  the  part 
of  the  profession,  which,  however,  has  no 
reasonable  basis,  provided  a  pure  drug 
can  be  obtained,  and  proper  precautions 
are  taken,  the  most  important  of  which 
is  to  prepare  the  solution  at  the  very 
moment  it  is  to  be  administered. 

The  value  of  apomorphine — according 
to  Carmichel,  who  voices  the  experience 
of  pediatricians  who  have  used  the  rem- 
edy extensively — cannot  be  too  highly 
esteemed  as  an  emetic  for  children;  the 
average  time  at  which  emesis  occurs  is 
much  less  than  the  period  required  by  the 
yellow  sulphate  of  mercury.  It  affords 
prompt  relief  in  croup  and  capillary  bron- 
chitis without  being  attended  by  nausea 
and  violent  retching,  which  makes  it  a 
great  boon  to  children. 

Apomorphine  used  after  antitoxin  in- 
jections in  laryngeal  diphtheria  wlien  the 
swelling  and  softening  of  the  false  mem- 
brane cause  signs  of  suffocation.  A 
hypodermic  dose  of  V12  grain  induces 
vomiting  and  clears  the  larynx.  Arn- 
stein  (Med.  News,  Apr.  8,  '99). 

It  is  an  expectorant,  in  doses  ranging 
from  Vso  to  ^/so  grain.  As  such  it 
affords  great  relief  in  cases  of  bronchitis, 
tracheitis,  and  catarrhal  pneumonia. 

A  spray  of  apomorphine  in  weak  solu- 
tion is  sometimes  recommended,  but  its 
use  in  this  manner  is  hardly  safe.  It 
has  been  found  valuable  in  whooping- 
cough  to  relax  spasmodic  attacks.  (In- 
gram.) 

It  has  recently  received  much  praise 
as  a  soporific — especially  in  acute  alco- 
holism. 

Apomorphine,  mixed  with  lanolin  and 
applied  to  the  skin,  is  a  most  valuable 
expectorant.  For  infants  the  strength  of 
the  ointment  should  be  1  grain  to  the 
ounce,  the  ointment  being  rubbed  over 
the  body  three  times  a  day,  the  skin 
being  previously  thoroughly  cleansed. 
C.  Smith  (Texas  Courier  Record,  Apr., 
'91). 


Case  of  a  man  suffering  from  paroxys- 
mal tonic  convulsions  with  flushed  face 
and  bounding  pulse.  The  condition  was 
assumed  to  have  been  caused  by  excess- 
ive indulgence  in  alcohol.  A  hypodermic 
containing  Vio  grain  of  apomorphine 
hydrochlorate  caused  free  emesis,  and 
was  followed  by  rapid  improvement.  J. 
Edward  Tompkins  (Med.  Record,  Jan. 
14,  '99). 

Apomorphine  as  an  hypnotic  found 
equally  useful  In  all  forms  of  insomnia 
regardless  of  the  cause.  It  should  be 
given  in  a  single  dose  of  about  V30  grain, 
injected  subcutaneously.  The  object  is 
to  give  a  dose  that,  on  the  one  hand,  is 
large  enough  to  produce  sleep,  and,  on 
the  other,  is  so  small  that  nausea  and 
vomiting  are  avoided.  Hence,  individual 
susceptibility  must  be  considered.  It 
should  be  given  when  the  patient  is  in 
bed,  for  its  effect  is  very  rapid  and  the 
patient  will  usually  fall  into  a  restful 
sleep  Avithin  five  to  twenty-five  minutes. 
If  no  results  are  observed  within  one-half 
hour  the  dose  is  too  small.  The  effect 
persists  for  from  one  to  two  hours,  but  in 
many  eases  of  insomnia  the  patient  will 
sleep  all  night.  C.  J.  Douglas  (N.  Y. 
Med.  Jour.,  Mar.  17,  1900) . 

Apomorphine  acts  as  a  prompt  and 
well-nigh  infallible  hypnotic  if  injected 
subcutaneously  in  doses  of  about  Vm 
grain.  Although  this  is  about  the  aver- 
age dose,  yet  for  some  patients  this  is 
too  large,  as  it  produces  nausea,  while  in 
others  a  larger  amount  will  cause  no  dis- 
agreeable symptoms.  The  dose  should  be 
so  adjusted  as  to  be  large  enough  to 
produce  sleep  and  small  enough  to  avoid 
nausea.  Douglas  (Merck's  Archives, 
June,  1900). 

Bronchitis. — Murrell  recommends 
that  apomorphine  be  given  in  large 
doses  as  an  expectorant  in  this  disease: 
V2  to  1  ^U  grains.  He  also  obtained 
excellent  results  from  an  ointment  of: 
apomorphine,  1  grain;  lard  or  lanolin, 
1  ounce;  the  half  of  which  is  rubbed 
into  the  chest:  a  point  of  very  great 
practical  importance,  especially  in  the 
treatment  of  children.    Murrell  also  ob- 


454 


APOMORPHINE.     THERAPEUTICS. 


served  the  expectorant  effect  in  many  by 
using  the  apomorphine  as  a  spray.  It 
was  very  marked  when  tlie  drug  was  used 
in  large  doses,  and  a  dose  which  would 
act  as  an  emetic,  if  administered  hypo- 
dermicallj',  can  be  used  as  an  inhalation 
without  giving  rise  to  this  result. 

Ceoup. — In  croup,  where  the  case  is 
urgent  or  where  an  expectorant  effect  is 
desired,  ^/loo  or  ^/eo  grain  every  fifteen 
min^^tes  gives  the  happiest  effect.  As 
relief  comes,  the  time  of  dosing  is  ex- 
tended to  one  or  two  hours,  but  the 
minimum  dose  is  continued.  When  it 
is  desirable  to  evacuate  the  stomach 
promptly,  no  remedy  meets  the  case 
better  than  apomorphine.  Cardiac  de- 
pression following  the  use  of  the  remedy 
should  be  promptly  met  by  suitable 
stimulants  and  tonics. 

Gastealgia. — From  the  fact  that  it 
produces  emesis  by  its  action  through 
the  spinal  nerve-centres,  and  not  by 
irritation  of  the  mucous  membrane,  it 
is  a  preferable  remedy  in  inflammatory 
conditions  of  the  stomach  where  emetics 
are  indicated. 

Case  of  indigestion  and  violent  gastral- 
gia  in  wliieli  aponiorpliine  was  given  hyp- 
odermically  to  produce  emesis.     Within 
two   minutes    the    patient   was    entirelj' 
free  from  pain,  fell  asleep  and  slept  for 
an  hour,  and  was  perfectly  comfortable 
afterward.      S.   F.   Morris    (N.   Y.    Med. 
Jour.,  Nov.  10,  '94). 
Poisoning.  —  The  value  of  apomor- 
phine as  an  antispasmodic  is  attested  by 
Edward  Balm,  of  Hyderabad,  who  tried 
it  in  a  distressing  case  of  hiccough  in 
a  man,  50  years  old,  who  had  suffered 
from  the  affection  for  about  six  months. 
It  is  thus  shown  to  be  doubly  valuable 
as  an  emetic  in  cases  of  poisoning  from 
the  ingestion  of  such  drugs  as  strych- 
nine, that  cause  tetanic  manifestations, 
although  after  poisonous  doses  of  drugs 
such  as  chloral — in  which  the  symptoms 


are    quite    the    opposite — it    is    equally 
useful. 

Case  in  which  recovery  followed  after 
a  large  dose  of  chloral.  The  patient,  a 
young  man,  had  taken  suicidally  3 
ounces  of  syrup  of  chloral  (B.  P.).  He 
was  found  in  the  morning  unconscious, 
Avith  cold,  clammy,  and  livid  body;  ster- 
torous respiration;  small  and  quick 
pulse,  and  dilated  pupils.  The  treat- 
ment consisted  of  an  hypodermic  injec- 
tion of  Vio  grain  of  apomorphine,  which 
was  followed  immediately  by  profuse 
vomiting;  the  injection  of  a  pint  of 
hot,  strong  coffee;  heaters,  and  flagella- 
tion. After  two  hours  of  treatment  the 
patient  could  speak  and  swallow  hot 
coffee.  He  continued  to  improve,  and 
in  twelve  hours  more,  though  somewhat 
dazed,  had  practically  recovered.  Hol- 
burton  (Brit.  Med.  Jour.,  Nov.  12,  '92). 

Case  of  attempted   suicide  by  strych- 
nine in  which  the  patient  had  swallowed 
a  pill  containing  1  %  grains  of  the  drug. 
Apomorphine,  cutaneous    frictions,    cold 
douches,    chloral-hydrate,    and    bromide 
of    potassium    brought    about    recovery. 
J.  Augustin  and  P.  Flor  (Spitalul,  Nos. 
11,  12,  '94). 
In  very  severe  cases  it  may  be  neces- 
sary to  administer  Vio  grain  every  ten 
minutes  until  some  effect  is  obtained,  or 
exhibit  '/^  grain  at  a  single  injection. 
In  feeble  persons  and  in  children  great 
caution  must  be  exercised. 

Case  of  strychnine  poisoning  in  which 
apomorphine,  in  doses  of  Vis  to  Vio 
grain,  subcutaneously  injected,  com- 
pletely subdued  the  convulsions,  and, 
eventually,  successfully  antagonized  the 
excitant  alkaloid.  Horsley  (Canadian 
Practitioner,  Dec.  6,  '90). 

Case  of  a  man  who  took  a  large  dose 
of  bromidia  and  became  violently  insane, 
requiring  three  men  to  control  him. 
Soon  after  receiving  ^/i,  grain  of  apo- 
morphine he  vomited,  had  a  movement 
of  the  bowels,  his  mental  condition  was 
relieved,  and  he  slept  well  the  remainder 
of  the  night.  Ingram  (Southern  Med. 
Record,  Apr.,  '92). 

Hysteeigal  Crises.  —  Apomorphine 
has  been  employed  in  a  large  number  of 


APPENDICITIS.    SYMPTOMS. 


455 


minor  hysterical  phenomena,  in  which 
the  remedy  gave  prompt  relief.  The 
amounts  used  varied  from  ^/g  to  ^/ao 
grain,  hypodermically  administered,  and 
were  never  followed  by  any  alarming 
symptoms.    (Horsley.) 

APOPLEXY.    See  Cerebral  H^mor- 

EHAGE. 

APPENDICITIS  (from  Latin,  appen- 
dere,  to  hang  on;  and  itis,  inflammation). 

Definition.  —  An  inflammation  of  the 
vermiform  appendix,  frequently  compli- 
cated with  ulceration  and  perforation  of 
its  coats,  caused  by  microbic  infection, 
which  may  originate  from  irritation  pro- 
duced by  hardened  fsecal  masses,  foreign 
bodies,  or  traumatism. 

Symptoms.  • —  Whether  catarrhal  or 
ulcerative,  the  attack  presents  itself  usu- 
ally in  a  previously  healthy  person  and 
begins  with  sudden  intense  pain  in  the 
right  iliac  fossa,  frequently  localized  at 
a  spot  one  and  one-half  to  two  inches 
from  the  anterior  superior  spine  of  the 
ileum  toward  the  umbilicus  (McBurney's 
point),  and  increased  by  pressure.  This 
is  the  most  important  diagnostic  sign 
■  when  associated  with  the  other  symp- 
toms. The  pain  may  radiate  from  this 
point  toward  the  umbilicus,  the  epigas- 
trium, the  groin,  and  the  testicles,  and 
be  attended  by  exacerbations.  It  may 
be  felt  in  other  parts,  especially  the 
epigastrium  and  the  umbilicus,  and  may 
even  be  located  in  the  left  iliac  fossa. 

One  of  the  most  significant  symptoms 
of  inflammation  of  the  appendix,  as 
distinguished  from  other  pathological 
conditions  that  may  develop  in  the  right 
iliac  fossa,  is  undoubtedly  the  tender- 
ness over  McBurney's  point.  Too  often 
it  is  assumed  by  the  practitioner  that 
there  must  be  spontaneous  pain  in  the 
right  iliac  fossa  whenever  acute  ap- 
pendicitis develops.    It  is  perfectly  pos- 


sible, however,  for  an  active  inflamma- 
tion of  the  appendix  to  be  dangerously 
progressive  without  the  slightest  pain 
in  this  region,  or  with  only  some  pass- 
ing discomfort  on  movement.  Yet  a 
touch  over  the  point  midway  between 
the  anterior  superior  spine  and  the  um- 
bilicus may  reveal  the  existence  of  ex- 
quisite tenderness.  This  is  the  signifi- 
cant value  of  the  diagnostic  symptom 
discovered  by  the  New  York  surgeon, 
and  the  real  reason  why  McBurney's 
point  has  attracted  the  attention  of  the 
medical  world.  Editorial  (Jour.  Amer. 
Med.  Assoc,  Aug.   16,  1902). 

Nausea  and  vomiting  are  present  in 
the  majority  of  cases,  but  it  does  not 
furnish  any  information  as  to  the  seri- 
ousness of  the  ease. 

Vomiting  present  in  208  out  of  a  series 
of  306  cases;  it  bodes  neither  good  nor 
ill.    Hood  (Lancet,  Sept.  18,  '97). 

Fulminating  appendicitis  observed  in 
three  cases.  In  each  case  there  was  a 
premonitory  stage  lasting  a  few  hours, 
during  which  the  patient  experienced 
abdominal  malaise.  The  acute  symp- 
toms which  somewhat  subsided  after 
several  hours,  followed  in  twenty-four 
hours  by  violent  and  sudden  increase 
of  all  symptoms.  A  few  hours  later 
pus,  with  a  perforated  and  non-adherent 
appendix,  was  found.  Gauze  was  used 
for  drainage  in  preference  to  a  tube. 
The  three  eases  recovered.  Richardson 
(Lancet,  Mar.  23,  1901). 
The  pulse  is  usually  high,  but  the  tem- 
perature-chart shows  brit  little,  if  any, 
rise. 

The  most  important  point  to  bear  in 
mind   in   the   diagnosis   of   appendicitis 
is  the  fact  that  the  temperature  of  the 
patient   is  a   matter  of  no   consequence 
as  giving  any  clue  to  the  condition  of 
the  appendix.     R.  T.  Morris  (Med.  Rec- 
ord, Dec.  26,  '96). 
Anorexia  and  digestive  disorders  are 
rarely  absent.     Diarrhoea  and  constipa- 
tion alternate,  but  either  symptom  may 
be  a  prominent  one  during  the  entire 
course  of  the  attack. 
Eigidity  of  the  right  abdominal  wall 


456 


APPENDICITIS.    SYMPTOMS. 


is  generally  present,  but  circumscribed 
rigidity  over  the  region  of  the  appendix 
is  present  in  about  one-half  of  the  cases. 
Circumscribed  muscle-tension  was  ob- 
served one  hundred  and  twenty  times  in 
three    hundred    cases.      Shrady    (N.    Y. 
Med.  Record,  June  6,  '94). 

If  the  case  be  one  of  simple  catarrhal 
appendicitis,  the  above  symptoms  con- 
tinue two  or  three  days  and  the  patient 
gradually  recovers. 

Leucocytosis  has  recently  been  sug- 
gested as  an  important  sign. 

Method  of  differential  diagnosis  more 
accurate  than  the  ordinary  clinical  meth- 
ods available,  viz.:  examination  of  the 
blood.  In  appendicitis  with  pus-forma- 
tion there  exists  a  typical  abscess,  and  in 
abscess-formation  there  is  an  increase  in 
the  number  of  leucocytes,  the  increase  be- 
ing proportionate  to  the  amount  of  pus- 
formation.  If  there  is  no  leucocytosis, 
the  case  is  either  not  one  of  appendicitis 
or  one  of  the  catarrhal  form,  and  ex- 
tremely mild,  or  very  severe  and  gan- 
grenous, the  patient  being  in  a  moribund 
condition.  This  means  of  diagnosis  and 
prognosis  should  be  given  a  trial.  H. 
Stuart  MacLean  (Virginia  Med.  Semi- 
monthly, Sept.  22,  '99). 

The  important  feature  is  to  differen- 
tiate between  the  catarrhal  and  non- 
penetrating forms,  and  the  septic  and 
gangrenous  forms,  of  appendicitis.  The 
following  general  rules  suggested:  A 
temperature  in  the  beginning  of  102°,  or 
a  temperature  above  100°  continuing 
until  the  second  day,  indicates  operation. 
A  rapid,  feeble  pulse,  without  rise  of 
temperature,  suggests  a  gangrenous  or 
septic  process.  Leucocytosis  of  more 
than  20,000  indicates  operation.  A.  L. 
Benedict  (Med.  News,  Deo.  1,  1900). 

In  the  diagnosis  of  suppurative  ap- 
pendicitis the  white  blood-count  is  of 
the  greatest  importance.  A  sudden 
hyperleucocytosis  points  to  a  complica- 
tion in  an  infectious  fever, — typhoid, 
for  instance, — and  if  sudden  abdominal 
pain  appear  an  exploratory  incision  is 
warranted,  as  is  the  practice  in  the 
Johns  Hopkins  Hospital.  Hyperleuco- 
cytosis   at    once    differentiates    a    sup- 


piirative  appendicitis  from  simple  co- 
litis, typhoid  fever,  ovarian  neuralgia, 
impaction  of  fteces,  and  floating  kidney. 
By  a  blood-count  pus  can  be  detected 
within  twenty-four  hours,  and  an  un- 
favorable prognosis  converted  into  a 
very  favorable  one.  Robbin  (Med. 
Record,  Oct.  27,  1900). 

Variations  from  the  above  course  are 
occasionally  met  with.  The  disease  may 
come  on  insidiously  and  fever  or  pain  be 
totally  absent.  Although  such  an  onset 
is  occasionally  met  with  in  adults,  it  is 
most  likely  to  occur  in  children.  Occa- 
sional colicky  pains  are  sometimes  the 
only  early  signs  furnished,  these  being 
followed  by  the  typical  symptoms  de- 
scribed above.  Slight  appendicular  le- 
sions may  be  accompanied  by  alarming 
symptoms  in  hysterical  patients,  or  in 
those  mentally  and  physically  below  par. 

Spurious  symptoms  often  cause  hesi- 
tation. Case  in  which  there  were  five 
attacks  with  symptoms  of  pericsecal  ab- 
scess and  intestinal  adhesions.  Soft  and 
rather  large  appendix  the  only  condi- 
tions present.  In  a  second  case,  in 
which  the  only  symptom  was  a  painful 
spot,  at  least  half  a  pint  of  pus  found. 
Routier  (Le  Bull.  Med.,  Jan.  30,  '95). 

The  symptoms  in  a  case  of  mild  catar- 
rhal appendicitis  cannot  at  pi'esent,  with 
certainty,  be  distinguished  from  those 
marking  onset  of  case  of  the  gravest 
type.  J.  W.  White  (Brit.  Med.  Jour., 
Feb.  9,  '96). 

When  examining  a  patient  great  at- 
tention should  be  paid  to  the  unequal 
susceptibility  shown  by  various  indi- 
viduals; some  react  but  little,  while 
others,  on  the  other  hand,  show  reflex 
symptoms  of  great  intensity.  Two  cases 
showing  that  very  slight  appendicular 
lesions  in  hysterical  patients  may  be  ac- 
companied by  extremely  alarming  symp- 
toms. Rendu  (La  Med.  Mod.,  Mar.  24, 
'97). 

The  majority  of  errors  in  the  diagno- 
sis of  intra-abdominal  inflammations 
consist  in  mistaking  atypical  forms  for 
other  morbid  conditions.  List  of  11 
cases  in  which  the  mistake  of  regarding 


APPENDICITIS.    SYMPTOMS. 


457 


as  appendicitis  conditions  which,  upon 
operation  or  necropsy,  proved  to  be 
other  and  unsuspected  pathological 
processes.  In  2  renal  calculus,  in  4  dis- 
eases of  the  uterine  appendages,  in  1 
sarcoma  of  the  ileum,  in  1  cholecystitis, 
in  1  acute  suppurative  pancreatitis,  and 
in  2  to  general  sepsis.  Brewer  (Annals 
of  Surg.,  May,  1901). 

Progress  toward  simple  perforation  or 
perforation  into  a  cavity  bound  by  ad- 
hesions is  probable,  when  on  the  third 
day  after  the  onset  of  the  symptoms  there 
is  localized  superficial  cedema,  indicating 
deep  suppuration,  and  when  a  doughy 
mass  is  felt  at  the  seat  of  pain,  which 
mass  gradually  assumes  shape  to  the 
touch,  unless  distended  intestinal  coils, 
shown  by  local  tympanites,  or  the  ten- 
sion of  the  abdominal  walls  makes  its 
detection  impossible. 

In  three  hundred  cases  the  tumor  in 
the  right  iliac  fossa  rarely  showed  itself 
before  the  third  day  of  pain  and  tender- 
ness. A  tumor  may,  however,  be  due  to 
accumulation  of  faeces  in  the  caecum. 
Dullness  on  percussion  is  rarely  recog- 
nized before  the  fourth  daj'.  G.  F. 
Shrady  (N.  Y.  Med.  Record,  Jan.  6,  '94). 

Fluctuation  does  not  generally  occur 
until  the  second  week.  CEdema  of  the 
overlying  integument  does  not  occur 
until  a  paratyphlitic  abscess  has  formed. 
G.  F.  Shrady  (N.  Y.  Med.  Eecord,  Jan. 
6,  '94). 

Diagnosis  is  made  almost  certain  by 
the  presence  of  a  bunch,  usually  situated 
in  the  right  lo\ver  quadrant  of  the  ab- 
domen or  near  the  liver  or  left  side.  It 
may  be  obscured  by  abdominal  disten- 
sion or  muscular  rigidity.  Gay  (Boston 
Med.  and  Surg.  Jour.,  Jan.  3,  '95). 

The  presence  of  slight  oedema  over  the 
loin  is  an  indication  of  the  presence  of 
deep-seated  suppuration.  Symonds  (Brit. 
Med.  Jour.,  .Jan.  26,  '95). 

According  to  Lewin,  the  local  applica- 
tion of  heat  will  show  whether  an  in- 
flammatory process  has  progressed  to 
suppuration  or  not.  In  appendicitis,  if 
pus  has  not  formed,  the  application  of 
heat  will  be  a  comfort  to  the  patient. 


If  pus  is  present,  the  pain  will  increase 
in  severity.  Eight  of  10  cases  in  which 
heat  was  applied  for  two  hours  bj'  hot 
compresses  experienced  marked  relief, 
while  in  the  other  2  there  was  increase 
of  pain.  These  2  died  from  extension 
of  the  suppuration.  Spohr  has  had  a 
similar  experience  in  15  cases.  Editorial 
(Therap.  Gaz.,  May  15,  1901). 

If  suppuration  is  present  and  perfora- 
tion occurs  on  the  fourth  or  fifth  day, — 
i.e.,  after  the  adhesions  have  formed, 
— the  symptoms  do  not,  as  a  rule,  vary 
from  those  enitmerated.  When,  how- 
ever, they  do  not  assume  a  graver  form 
during  the  first  four  days,  the  presence 
of  protective  adhesions  is  likely. 

Danger  may  exist  without  being  shown 
by  pulse  or  temperature.  Pulse,  tem- 
perature, and  pain  may  decline,  marking 
the  occurrence  of  effusion:  a  deceptive 
calm.  The  sudden  access  of  intense  local- 
ized pain  indicates  a  dangerous  change 
in  the  local  conditions.  6.  F.  Shrady 
(N.  Y.  Med.  Record,  Jan.  6,  '94). 

A  pulse-rate  of  120  indicates  a  con- 
siderable infection,  and,  according  to 
some,  is  an  absolute  indication  for  opera- 
tion. Richardson  (Amer.  Jour.  Med. 
Sciences,  Jan.,  '94). 

Too  much  stress  must  not  be  laid  on 
the  temperature,  as  recovery  may  follow 
a  temperature  of  105°  F.  and  death  may 
occur  with  one  nearly  normal.  Richard- 
son (Amer.  Jour.  Med.  Sciences,  Jan., 
'94). 

When  the  symptoms  are  marked  and 
a  tumor  cannot  be  felt,  perforation  has 
probably  occurred  before  the  adhesions 
were  sufficiently  perfect  to  protect  the 
peritoneal  cavity. 

If  perforation  has  occurred  early, — 
i.e.,  while  the  adhesions  were  still  im- 
perfect, —  there  is  usually  a  chill  and 
vomiting;  shock,  more  or  less  profound; 
diffuse,  marked  pain,  instead  of  the  lo- 
calized pain;  acceleration  of  the  pulse; 
an  increase  of  temperature  of  3°  or  3° 
F.;  scanty  and  dark  itrine,  showing  high 
specific  gravity. 


458 


APPENDICITIS.     SYMPTOMS. 


The  cause  of  diflfuse  peritonitis  com- 
plicating appendicitis,  ascertained  by 
personal  clinical  observations,  is  as  fol- 
lows: 1.  Peristaltic  motion  of  the  small 
intestines  is  the  chief  means  of  carrying 
the  infection  from  the  perforated  or 
gangrenous  appendix  to  the  other  por- 
tions of  the  peritoneum,  changing  a  cir- 
cumscribed   into    a   general    peritonitis. 

2.  This  can  be  prevented  by  prohibiting 
the  use  of  every  kind  of  food  and 
cathartics  by  mouth,  and  by  employing 
gastric  lavage  in  every  case  in  which 
there  are  remnants  of  food  in  the  stom- 
ach or  in  the  intestines  above  the  ileo- 
csecal  valve,  as  indicated  by  the  pres- 
ence of  nausea,  vomiting,  or  meteorism. 

3.  The  patient  can  be  supported  by  the 
use  of  concentrated  predigested  food  ad- 
ministered as  enemata  not  oftener  than 
once  in  four  hours,  and  not  in  larger 
quantities  than  4  ounces  at  a  time.  4. 
This  form  of  treatment,  when  instituted 
early,  will  change  the  most  violent  and 
dangerous  form  of  acute  perforative  or 
gangrenous  appendicitis  into  a  compara- 
tively mild  and  harmless  form.  A.  J. 
Ochsner  ( Amer.  Surg,  and  Gynaec,  Jan., 
1902). 

Perforation  is  also  accompanied  by 
distension  of  the  abdomen,  and  symp- 
toms of  grave  diffuse  peritonitis  appear, 
followed  by  collapse.  Dullness  affords 
an  early  clue  to  the  presence  of  pus. 

Distension  of  the  abdomen  depends,  for 
its  importance,  upon  its  cause.  Opium 
may  cause  it  or  gas  may  form.  If  peri- 
stalsis is  not  inhibited  no  alarm  need  be 
felt.  Distension  due  to  local  infection 
is  of  the  gravest  import.  Richardson 
(Amer.  Jour.  Med.  Sciences,  Jan.,  '94). 

Increase  of  both  pulse  and  temperature 
from  a  condition  showing  a  slightly  ac- 
celerated pulse  and  a  temperature  of  100° 
to  101°  F.,  combined  with  increase  of 
the  other  symptoms,  indicate  a  danger- 
ous condition.  G.  F.  Shrady  (N.  Y.  Med. 
Record,  Jan.  6,  '94). 

General  abdominal  distension  is  the 
most  dangerous  symptom.  Gage  (Boston 
Med.  and  Surg.  Jour.,  May  24,  '94). 

A  point  of  marked  dullness  in  cases 
without  any  pronounced   inflammatory 


symptoms  was  always  found  when  the 
appendix  was  indurated  and  adherent  to 
the  adjacent  tissue.     In  all  of  19  cases 
in  which  dullness  was  present  pus  was 
diagnosed.     This  was  verified  either  by 
operation   or  by   autopsy,  except   in   2 
cases.     H.  T.  Miller  (Med.  Record,  Feb. 
9,  1901). 
The  actinomycotic  form  is  character- 
ized by  slower  progress  and  less  acute 
symptoms. 

In  the  rheumatic  form  there  is  miich 
tenderness  over  the  appendix.  No  tumor 
or  dullness  can  be  detected.  Arthritis, 
however,  is  present. 

Case  of  rheumatic  perityphlitis  show- 
ing much  tenderness  in  the  right  iliac 
fossa,  but  no  tumor  or  dullness;  with 
arthritis.  The  diagnosis  proved  by  the 
fact  that  the  salicylates  rapidly  pro- 
duced a  beneficial  eflfeot.  I.  Burney  Yeo 
(Brit.  Med.  Jour.,  June  10,  '94). 

The  infectious  form  is  distinguished 
by  a  rapid  course. 

The  disorder  called  by  Poncet  "acute 
infectious   appendicitis"  is   distinguished 
by  its  rapid  involvement  of  the  perito- 
neum, without  ulceration,  perforation,  or 
gangrene.     It  results  from  occlusion  of 
the   orifice   of  the   appendix  by  inflam- 
mation, and  absorption  of  its  contents; 
the   presence   of   the   bacillus    coli   com- 
munis is  thought  also  to  have   an   im- 
portant influence.    Clinically,  it  does  not 
difi^er   from   other  forms   of  the    disease 
except    in    its    rapid    course.      Margery 
(Jour,    de   Med.    et    de    Chir.    Pratique, 
Feb.  25, '93). 
When  appendicitis  occurs  during  preg- 
nancy, the  attack  is  usually  sudden  and 
begins  with  abdominal  pain  which  grad- 
ually becomes  localized;  this  is  followed 
by  the  typical  symptoms.  This  condition 
must   be    carefully   differentiated   from 
tubal  pregnancy.   The  prognosis  is  grave. 
Appendicitis  complicating  pregnancy  is 
difficult  of  recognition  and  the  cause  of 
great    mortality.      Hrawacek    cites    13 
cases  of  catarrhal  appendicitis  with  preg- 
nancy,   5    cured    without    operation,    11 
operations,  and  7  deaths.    Case  in  which 


APPENDICITIS.     DIAGNOSIS,  GENERAL. 


459 


abscess  associated  with  a  necrosed  ap- 
pendix was  removed  without  disturbing 
the  pregnancy;  three  months  afterward 
the  patient  gave  birth  to  a  healthy  child, 
having  a  normal  delivery  and  puerpe- 
rium.  Appendicitis  sometimes  appears 
as  a  complication  of  diseases  of  ovaries 
and  appendages.  Martin  in  171  oper- 
ations for  right-sided  salpingitis  and  276 
double-sided  found  appendicitis  6  times 
in  connection  therewith;  Dilhrssen  in 
one  and  one-half  years,  out  of  322  lapa- 
rotomies, had  10  eases  of  diseased  ap- 
pendix; Ochsner,  of  Chicago,  in  51  oper- 
ations for  primary  appendix  found  15 
times  secondary  disease  of  the  append- 
ages. Otto  Falk  (Centralb.  f.  Gynilk., 
Feb.  17,  1900). 

Diagnosis,  General.  —  During  exami- 
nation gentle  manipulation  is  necessary, 
lest  an  abscess  be  present  and  the  adhe- 
■sions  he  delicate  and  unable  to  stand  the 
traction  or  pressure.     (McBurney.) 

The  amount  of  manipulation  necessary 
to  make  a  complete  diagnosis  should  be 
of  the  very  lightest  possible  kind.  Any- 
thing more  than  very  light  manipulation 
in  one  of  these  cases  must  be  accom- 
panied by  a  certain  amount  of  danger, 
because  we  do  not  know  the  thickness 
of  the  barrier  between  abscess-cavity  and 
the  peritoneum.  McBurney  (Buffalo 
Med.  Jour.,  June,  '96). 

The  location,  direction,  and  extent  of 
the  appendix  have  an  important  bearing 
on  the  clinical  history  of  appendicitis, 
considering  the  variations  of  the  appen- 
dix in  length,  direction,  and  location, 
and  the  varying  site  of  the  cscum. 

It  is  quite  possible  to  feel  the  normal 
appendix  in  most  cases.  If  one  palpates 
gently  with  two  or  three  fingers  on  the 
opposite  side  one  can  readily  get  the 
landmarks.  The  ascending  colon  is  the 
first  landmark.  Three  fingers  are  placed 
upon  the  rectus  muscle,  then  brought 
down  over  the  edge  of  the  muscle,  three 
fingers  of  the  right  hand  being  used  to 
feel  with  and  the  three  fingers  of  the 
left  hand  to  press  with.  The  examining 
fingers  are  pressed  by  means  of  the  three 


others  down  under  the  border  of  the 
right  rectus  abdominis  muscle  at  the 
level  of  the  navel,  and  slowly  drawn  to 
the  examiner.  The  landmark,  the  as- 
cending colon,  is  then  felt  to  slip  out 
from  under  the  fingers,  and,  by  repeating 
the  process  toward  the  csecum,  one  soon 
comes  to  the  end  of  the  latter,  and  there 
begins  to  hunt  for  the  appendi.x  by  roll- 
ing the  CEecum  to  one  side  or  the  other 
of  the  finger-tips.  The  proximal  end  of 
the  appendi.x  is  found  near  the  distal 
end  of  the  caecum;  the  remainder  of  the 
appendix  is  followed  in  any  direction. 
The  proportion  of  appendices  that  cannot 
be  palpated  will  become  smaller  as  the 
finger-tips  become  educated.  The  very 
delicate  sense  of  touch  is  preserved  if  the 
left  hand  is  used  for  pushing  upon  the 
examining  hand.  Robert  T.  Morris  (In- 
ternational Jour,  of  Surg.,  Aug.,  '98). 

Auscultation  of  the  lungs  and  heart 
sometimes  affords  information. 

Examination  through  the  rectum  is  of 
value  in  determining  the  presence  of  pus 
in  advanced  cases.  In  the  earlier  stages 
this  procedure  is  of  no  value. 

Examination  of  the  urine  may  assist 
in  the  location  of  the  inflammatory  proc- 
ess and  in  determining  the  activity  of 
metabolic  processes.  Glycosuria  was  also 
found  present  in  three  cases  examined 
by  Leidy. 

In  228  consecutive  cases  of  appendicitis 
in  which  there  was  an  operation  there 
were  7  errors  in  diagnosis;  these  include 
1  each  of  old  typhoid-fever  complications, 
peritoneal  tuberculosis,  cancer  of  appen- 
dix, congestion  of  appendix,  hysteria, 
pneumonia,  and  sequelae  of  measles.  As 
the  number  of  errors  is  small  compared 
with  the  total  number  of  cases,  it  is  con- 
cluded that  appendicitis  is  one  of  the 
most  readily  diagnosed  of  all  diseases. 
In  4  of  the  eases  in  which  an  incorrect 
diagnosis  was  made  the  operation  was 
of  benefit  to  the  patient.  Robert  T. 
Morris  (N.  Y.  Med.  Jour.,  Apr.  8,  '99). 
The  youngest  patient  on  record  oper- 
ated on  was  sixty-one  days  old.  Chil- 
dren seem  to  bear  general  septic  infec- 
tion better  than  adults.     The  two  con- 


460 


APPENDICITIS.    DIAGNOSIS,  DIFFERENTIAL. 


ditions  from  which  infantile  appendi- 
citis must  be  differentiated  are  intus- 
susception and  tuberculous  peritonitis. 
The  most  reliable  source  of  information 
lies  in  the  careful  examination  of  the 
abdominal  wall,  which,  in  a  child,  is  very 
easily  accomplished.  Abdominal  disten- 
sion, frequent  and  shallow  respiration 
are  common.  T.  H.  Manley  (Jour. 
Amer.  Med.  Assoc,  June  1,  1901). 

Every  death  from  appendicitis,  in  an 
individual  otherwise  well,  excepting 
those  of  the  fulminating  type,  could 
have  been  prevented  by  the  use  of  the 
knife  at  the  proper  time.  If  one  is  to 
operate  early,  an  early  diagnosis  is 
necessary.  If  the  three  cardinal  symp- 
toms of  appendicitis  are  kept  in  mind, 
the  early  diagnosis  is,  in  nine  eases  out 
of  ten,  very  simple.  The  three  cardinal 
symptoms  are  pain,  tenderness,  and 
rigidity.  J.  B.  Deaver  (New  York  Med. 
Jour.,  Dee.  7,  1901). 

We  can  best  diagnose  the  locality  of 
the  disease  by  the  following  method: 
Ask  the  patient  to  point  the  finger 
quickly  to  the  spot  where  there  is  the 
most  pain  without  looking  at  the  abdo- 
men. Eepeat  this  proceeding  a  number 
of  times  until  you  are  certain  that  the 
right  point  has  been  obtained.  Then 
the  course  of  the  appendix  will  lie  be- 
tween the  base  of  the  organ  and  this 
point.  Where  no  mass  can  be  felt  in 
the  region  it  is  impossible  correctly  to 
diagnose  a  perforation  or  gangrene. 
Where  the  mass  can  be  felt  and  persists 
longer  than  two  or  three  days  without 
diminishing  in  size  or  indeed  even  in- 
creasing, it  always  has  pus  for  a  nu- 
cleus. C.  A.  Elsberg  (Med.  Record,  April 
5,  1902). 

There  are  a  certain  number  of  cases 
in  which  the  diagnosis  of  appendicitis 
is  so  evident  that  no  one  questions  the 
propriety  of  operation.  There  are  other 
cases  in  which  the  symptoms  remain 
permanently,  subjecting  the  patient  to 
frequent  exacerbations.  There  is  a  third 
class  in  which  the  symptoms  abate 
never  to  return,  on  the  one  hand,  or 
to  return  at  intervals,  on  the  other 
hand,  until  relieved  or  until  death  oc- 
curs. In  any  case  of  appendicitis  in 
which  the   diagnosis   is   undoubted   and 


the  services  of  a  competent  surgeon  can 
be  secured,  operation  should  be  done. 
James  Tyson  (Proceedings  Amer.  Med. 
Assoc;  Phila.  Med.  Jour.,  June  21, 
1902). 

Diagnosis,  Differential. 

Intestinal  Obstruction.  —  In  this 
disorder  the  rise  of  temperature  occurs 
late.  Stercoraceous  vomiting  is  observed 
in  serious  eases.  Volvulus  generally  pre- 
sents itself  in  children. 

Typhlitis.  —  This  disease  is  charac- 
terized by  a  gradual  onset,  a  typhoid 
course,  and  a  prolonged  convalescence. 

The  pain  on  pressure  in  typhlitis  is 
dull,  while  in  appendicitis  it  is  sharp. 
Typhlitis  is  more  a  disease  of  corpulent 
aged  individuals  leading  a  sedentary  life; 
appendicitis  is  an  affection  of  young 
adult  males.  Benoit  (L'Union  Med.  du 
Canada,  Mar.,  '94). 

Esecal  distension  of  the  caecum  some- 
times causes  irritation  of  the  mucous 
membrane,  and  presents  symptoms  sim- 
ilar to  those  of  appendicitis.  This  con-, 
dition  may  be  excluded  by  the  fact  that 
the  tumor  preceded  the  pain,  by  the  ab- 
sence of  vomiting  and  rigidity  of  the 
abdominal  wall,  and  by  the  small  amount 
of  pain  and  tenderness.  Typhoid  fever 
is  to  be  excluded  by  gradual  rise  and 
higher  temperature  range,  by  the  absence 
of  tumor  and  rigidity  of  the  muscles  in 
the  right  iliac  region,  and  by  the  nervous 
phenomena  and  spots.  In  typhoid  fever 
the  characteristic  stools  will  probably  be 
found,  and  in  appendicitis  constipation, 
or,  if  diarrhoea,  it  is  not  characteristic. 
Intestinal  obstruction  presents  the  symp- 
toms of  shock  from  the  first,  if  it  is 
acute,  and  there  is  no  elevation  of  tem- 
perature. The  constipation  is  more 
marked  than  in  inflammation  of  the  ap- 
pendix, save  in  those  cases  where  paresis 
of  the  intestine  is  present.  Vomiting  is 
a  characteristic  symptom  of  intestinal 
obstruction.  In  renal  calculus  the  pain 
radiates  from  the  right  lumbar  region  to 
the  hypogastrium  and  is  very  severe,  but 
disappears  after  the  lapse  of  some  hours 
as  quickly  as  it  came.  The  testicle  is 
retracted    and    the    patient    is    without 


APPENDICITIS.     DIAGNOSIS,  DIFFERENTIAL. 


461 


fever.  The  absence  of  fever  by  no  means 
excludes  appendicitis,  however.  Gall- 
stones may  be  simulated  by  an  abnor- 
mally located  appendix  which  is  in- 
flamed. In  the  female  inflammation  of 
the  Fallopian  tube  and  extra-uterine 
pregnancy  can  usually  be  excluded  by  a 
bimanual  examination  in  connection  with 
the  clinical  history  of  these  conditions. 
J.  Garland  Sherrill  (Louisville  Jour,  of 
Surg,  and  Med.,  Apr.,  '99). 

A  number  of  cases  of  chronic  colitis 
seen  in  which  the  question  was  raised 
as  to  wnether  the  condition  was  not 
really  a  chronic  appendicitis,  but  no 
case  of  acute  appendicitis  of  so  grave 
a  nature  had  been  seen  as  to  mal^e  it 
unsafe  to  give  a  laxative  or  injection 
for  fear  of  producing  perforation  where 
the  question  was  raised  as  to  whether 
the  condition  was  really  an  acute  ap- 
pendicitis or  acute  colitis.  When  per- 
foration is  threatened  in  acute  ap- 
pendicitis, the  diagnosis  is  usually  not 
difBcnlt  to  make.  One  or  two  cases  of 
unmistakable  chronic  colitis  personally 
.  seen  which  were  entirely  cured  by  re- 
moval of  a  diseased  appendix.  This 
would  seem  to  indicate  that  the  inflam- 
mation in  these  eases  had  begun  in  the 
appendix  and  extended  to  the  colon,  the 
primary  and  chief  lesion,  however,  being 
in  the  appendix.  McBurney  (Med.  Rec- 
ord, April  19,  1902). 

•  TuBEECULAK  TYPHLITIS.  —  Slow  as- 
thenic course,  diarrhoea,  and  a  higher 
temperature  usually  distinguish  this  dis- 
ease. 

The  diagnosis  between  appendicitis 
and  tuberculous  typhlitis  is  often  ob- 
scure. The  latter  may  be  localized  at 
one  point  of  the  csecum,  causing  a  small, 
hard  tumor  without  viscous  surround- 
ings. Rlehelot  (L'Union  Med.,  Nos.  39, 
40,  '92). 

Case  in  which  symptoms  of  appendi- 
citis were  such  as  to  leave  little  room 
for  doubt.  Nevertheless,  the  appendix 
was  free  from  disease,  and  tuberculous 
ulceration  and  narrowing  of  the  caecum 
were  alone  found  after  death  to  account 
for  the  symptoms.  H.  W.  Page  (Lancet, 
.July  3,  '97). 


TuMOES.  —  In  cancer— the  neoplasm 
which  occurs  most  frequently  in  the 
intestines — the  subject  is  usually  beyond 
his  fortieth  year.  Slow  progress  and  the 
cachectic  face  are  important  differenti- 
ating signs. 

Judgment  should  not  be  passed  too 
hastily  on  tumors  in  the  caecal  region; 
eight  cases  in  which  tumors  of  that  re- 
gion were  connected  with  the  csecum. 
Richelot  (L'Union  Mfidicale,  Apr.  2,  '92). 
Case  of  epithelioma  of  the  caecum  and 
appendix  simulating  recurrent  appendi- 
citis. Sourdille  (Bull,  de  la  Soc.  Anat., 
Dec,  '94). 

Myxoma  of  vermiform  appendix  simu- 
lating recurrent  appendicitis,  in  a  girl, 
aged  23,  admitted  with  a  history  of  two 
attacks  of  (supposed)  appendicitis.  The 
appendix  was  thickened  at  the  end,  and 
upon  being  opened  showed  a  pellucid 
shining  tumor  the  size  of  a  small  bean. 
No  record  of  a  similar  specimen  found. 
Churton  (Brit.  Med.  Jour.,  May  15,  '97). 
In  the  case  of  a  boy  with  symptoms  of 
chronic  appendicitis  there  was  found  by 
operation  a  round-celled  sarcoma  of  the 
appendix  with  involvement  of  the  mesen- 
teric glands;  patient  recovered  after  re- 
moval of  the  csecum,  a  portion  of  the 
ileum,  and  a  V-shaped  piece  of  mesentery. 
J.  C.  Warren  (Boston  Med.  and  Surg. 
Jour.,  Feb.  24,  '98). 

Anomalous  cases  of  appendicitis  which 
may  be  mistaken  for  neoplasms  in  the 
iliac    fossa.      A    hard    tumor    develops 
slowly,  with  progressive  emaciation  and 
cachexia.     After  a  long  period  the  mass 
becomes  softer,  evidences  of  suppuration 
appear,  and  on  making  an  incision  pus 
is  evacuated,  the  tumor  then  disappear- 
ing.    Legueu  and  Beaussenat  (Revue  de 
Gynec.  et  de  Chir.  Abdora.,  No.  2,  '98). 
Typhoid  Fevee. — Perforation  occurs 
late  in  this  disease,  while  the  tempera- 
ture, the  petechia,  and  other  character- 
istics readily  serve  to  distinguish  it. 

When  there  is  doubt  as  to  whether  a 
case  is  typhoid  or  appendicitis,  the 
operation  should  be  postponed  if  con- 
stitutional signs  are  severe  and  local 
ones  hard  of  detection.  When  the  ab- 
dominal   symptoms  —  pain,    tenderness. 


462 


APPENDICITIS.     DIAGNOSIS,  DIFFERENTIAL. 


rigidity,  with  or  -without  distension — 
call  loudly  for  operation,  the  abdomen 
must  be  opened,  in  spite  of  the  possi- 
bilities of  typhoid;  but  cases  suggesting 
typhoid  as  strongly  as  appendicitis 
should,  until  the  diagnosis  is  perfectly 
clear,  be  carefully  observed.  One  should 
proceed  in  doubtful  eases  with  extreme 
caution;  every  means  of  investigation 
should  be  exhausted  before  subjecting 
the  patient  to  an  operation.  In  those 
cases  in  particular  in  which  the  sus- 
picion of  typhoid  fever  is  present,  the 
abdomen  should  not  be  opened  unless 
the  indications  are  strong.  When,  in 
spite  of  repeated  examinations  and  the 
greatest  care,  the  surgeon  is  convinced 
that  tj'phoid  fever  is  not  present,  ex- 
ploration, even  if  it  proves  him  wrong 
and  shows  that  typhoid  does  really  ex- 
ist, loses  the  sting  of  carelessness  and 
haste.  The  blunders  that  mortify  are 
those  which  would  be  unnecessary  were 
the  examination  painstaking.  M.  H. 
Kichardson  (Boston  Med.  and  Surg. 
Jour.,  Jan.  9,  1902). 

DisoRDEES  OF  THE  UTERUS,  adnexa, 
and  pelvic  cellular  tissue,  especially  sal- 
pingitis, are  conditions  which  may  cause 
confusion,  especially  the  latter.  Exam- 
ination of  the  genito-urinary  organs 
sometimes  establishes  the  differential 
diagnosis. 

By  placing  the  patient  on  her  left 
side  with  the  shoulders  low  and  the  legs 
drawn  up,  it  is  much  more  easy  to  de- 
tect the  position  and  condition  of  the 
appendix  and  also  to  differentiate  it 
from  the  uterine  adnexa  than  by  palpa- 
tion of  the  patient  lying  on  her  back. 
Even  when  no  great  intestinal  distension 
is  present,  the  depth  at  which  the  appen- 
dix might  lie  is  greater,  and  the  tension 
of  the  abdominal  walls  is  likely  to  be 
more  marked  in  the  dorsal  position  than 
when  this  lateral  method  is  employed, 
if  no  intestinal  adhesions  are  present. 
(J.  C.  Simpson.) 

In  appendicitis  the  pains  are  more 
violent,  but  more  strictly  localized,  and 


radiating  pains  are  absent.  In  catarrhal 
salpingitis,  especially  if  the  ovaries  share 
in  the  inflammation  of  the  tubes,  the 
pains  radiate  toward  the  thigh;  the 
alarming  symptoms  also  show  a  notice- 
able remission  toward  the  third  or  fourth 
day.    (Vineberg.) 

In  an  acute  progressive  case  the  ab- 
domen is  so  rigid  that  deep  palpation  is 
difiicult  and  dangerous.  A  rigid  abdo- 
men is  the  principal  differential  sign 
between  acute  appendicitis  and  salpin- 
gitis.    (E.  T.  Morris.) 

Simple  appendicular  colic  or  parietal 
inflammation  of  the  appendix  may  be 
accompanied,  in  hysterical  persons,  espe- 
cially women,  by  nervous  symptoms, 
simulating  severe  diffuse  peritonitis. 
Talamon  (Med.  Mod.,  No.  24,  '97). 

Three  eases  of  tubo-ovarian  congestion 
diagnosed  as  appendicitis.  Colicky  pains 
in  the  right  iliac  region  five  days  after 
the  end  of  the  menstrual  period;  simi- 
lar attack  a  year  previously.  A  rectal 
and  vaginal  examination  revealed  a  re- 
troflexed  uterus,  with  enlarged  tender 
ovary  and  tube  on  the  right  side.  J.  C. 
MacEvitt  (Brooklyn  Med.  Jour.,  Apr., 
'97). 

Six  cases  of  appendicitis  in  the  female 
in  which  it  Avas  impossible  to  positively 
establish  the  diagnosis  before  opening 
the  abdomen.  If  the  pain  and  the  tumor 
are  high  up  in  the  region  of  the  right 
tube  and  ovary,  appendicitis  probably 
present.  If  the  hymen  is  intact  an  in- 
flammatory enlargement  on  the  right 
side  is  probably  due  to  appendicitis. 
Eichelot   (Le  Gyngc,  June,  '97). 

Acute  puerperal  parametritis  may  be- 
gin in  the  same  manner  as  perforation 
of  the  appendix,  but  the  symptoms  are 
less  severe,  those  of  diffuse  peritonitis 
being  absent. 

It  is  more  difficult  to  distinguish  be- 
tween perforation  of  the  appendix  and 
the  rupture  of  a  pus-tube  or  ovary.  If 
recovery  takes  place,  the  parametritis 
and  paratyphlitis  exudates  can  usually 
be  diagnosticated  by  their  characteristic 
shape  and  position.  Kriiger  (Deut.  Zeit. 
f.  Chir.,  B.  45,  H.  3  and  4). 


APPENDICITIS.    DIAGNOSIS,  DIFFERENTIAL. 


463 


Diagnosis  is  not  easy  when  inflamma- 
tion of  tlie  right  tube  and  ovary  and  of 
the  appendix  occur  at  the  same  time. 
We  have  in  both  rapid  pulse,  rise  of 
temperature,  pain,  vomiting,  and  tym- 
panites. However,  appendicitis  begins 
more  acutely.  If  a  chronic  case,  there 
is  a  history  of  one  or  more  former  sharp 
and  sudden  attacks.  Lesions  of  tubes 
and  ovaries  are  of  older  date  and  have  a 
history  of  menstrual  disorder.  Pain  of 
appendicitis  is  acute,  frequently  violent, 
beginning  over  the  solar  plexus,  radi- 
ating over  the  whole  belly,  and  finally 
settling  in  the  right  iliac  region.  In  ad- 
nexal  disease  the  pain  is  dull  and  heavy, 
and  never  sharp  and  lancinating  until 
the  peritoneum  is  involved.  Patient  is 
more  alarmed  in  appendicitis  than  in  dis- 
ease of  the  adnexa.  Location  of  tender- 
ness is  different:  in  appendicitis  it  is  on 
a  level  with  the  anterior  spine;  in  ad- 
nexa, trouble  is  in  the  pelvis.  In  the 
latter,  vaginal  examination  reveals  the 
site  of  tenderness;  in  the  former,  one 
can  touch  and  move  the  organs  in  the 
pelvis  without  producing  pain.  Vomit- 
ing is  more  common  in  appendicitis. 
Rigidity  of  the  muscles  of  the  abdomi- 
nal wall  over  the  right  iliac  region  is 
almost  always  present  in  appendicitis, 
and  generally  absent  in  inflammation  of 
the  tubes  and  ovaries.  In  case  of  doubt 
chloroform  should  be  given,  and  by  its 
aid  the  enlarged  and  tortuous  appendix 
can  be  felt  or  by  a  bimanual  examination 
disease  of  the  adnexa  may  be  discovered. 
Hunter  McGuire  (Southern  Med.  Record; 
Canada  Lancet,  May,  '98). 

Neuralgia  in  the  region  of  the  appen- 
dix, renal  colic,  particularly  when  pro- 
tracted and  febrile,  cholecystitis,  per- 
foration of  duodenal  or  other  ulcers  along 
the  gastro-intestinal  tract  and  diseases 
of  the  internal  genitalia  may  simulate 
this  affection.  E.  G.  Janeway  (Med. 
Record,  May  26,  1900). 

Appendicitis  is  much  more  common  in 
women  than  is  supposed,  because  of  the 
frequency  with  which  it  is  mistaken  for 
ovaritis  of  the  right  side.  Several  per- 
sonal patients  had  been  treated  for  a 
prolonged  period.  The  pain  of  appendi- 
citis is  more  sudden  in  its  onset,  and 
much  more  acute  and  is  often  accom- 


panied with  nausea.  Muscular  spasm 
is  usually  marked;  the  general  dis- 
turbance is  greater,  and  the  progress 
more  rapid.  An  intact  hymen  points  to 
appendicitis.  F.  W.  McRae  (N.  Y.  Med. 
Jour.,  Feb.  2,  1901). 

Miscellaneous  Disohdees. — Accord- 
ing to  Deaver,  movable  kidney  is  to  be 
differentiated  as  follows:  In  appendicitis 
there  is  more  apt  to  be  fever  and  in- 
creased pulse-rate,  the  rigidity  of  the 
abdominal  wall  does  not  involve  such  a 
large  area,  there  is  a  circumscribed  and 
acutely-tender  point,  the  tenderness  is 
more  superficial,  and  there  is  an  absence 
of  a  movable  tumor  which  readily  slips 
from  between  the  examiner's  fingers. 

Chronic  appendicitis  is  present  in  from 
80  to  90  per  cent,  of  women  with  symp- 
tom-producing movable  right  kidney. 
This  frequency  constitutes  chronic  ap- 
pendicitis one  of  the  chief,  if  not  the 
chief,  symptoms  of  movable  kidney. 
Twenty  per  cent,  of  all  women  have 
movable  kidney  or  kidneys;  4  per  cent, 
of  all  women  have  symptom-producing 
movable  kidney  or  kidneys;  4  per  cent, 
of  all  women  have  appendicitis,  while 
3  Vs  per  cent,  of  all  women  have  both 
symptom-producing  movable  kidney  and 
appendicitis;  only  'Z™  per  cent,  of 
all  women  have  appendicitis  and  well- 
anchored  kidneys.  A  movable  left  kid- 
ney never  produces  appendicitis.  Mov- 
able right  kidney  probably  produces 
chronic  appendicitis  by  indirect  pressure 
upon  the  mesenteric  vein,  the  return- 
circulation  of  the  appendix  being  ham- 
pered by  compression  of  the  vein  between 
the  head  of  the  pancreas  and  the  spinal 
column.  George  M.  Edebohls  (Post- 
graduate, Feb.,  '99). 

Infectious  catarrhal  inflammation  of 
the  iile-duds  and  ulceration  of  these 
ducts  may  occasionally  simulate  appen- 
dicitis. Biliary  colic  is  to  be  differen- 
tiated by  jaundice,  absence  of  fever, 
peculiar  color  of  the  stools,  finding  of 
gall-stones  in  the  passage,  and  by  the 
more  severe  and  continuous  pain,  radiat- 


464 


APPENDICITIS.    ETIOLOGY. 


ing  usually  from  the  chest-margin  to  the 
umbilicus. 

Simple  empyema  of  the  gall-lladder  is 
diagnosed  by  the  onset,  the  location  and 
character  of  the  pain  and  tenderness,  and 
by  the  area  and  degree  of  rigidity. 

Acute  phlegmonous  cholecystitis  and 
gangrene  of  the  gall-bladder  may  usually 
be  diagnosed  by  the  existence  of  more 
acute  symptoms,  more  general  perito- 
nitis, by  the  rapid  and  shallow  respira- 
tion, location  of  the  pain  and  tenderness, 
and  by  the  greater  tendency  to  a  rapidly 
fatal  issue. 

Perforated  gastro-intestinal  ulcers  are 
diagnosed  by  predisposing  age,  history 
of  previous  gastric  or  intestinal  disturb- 
ances, sudden  acute  pain  in  the  epigas- 
trium, followed  by  collapse,  and  last 
by  the  presence  of  bloody  vomiting,  or, 
in  the  case  of  intestinal  ulcers,  by  the 
haemorrhage  from  the  bowel.  Perfora- 
tion occurring  in  typhoid  may  be  very 
difficult  to  tell  from  a  concurrent  ap- 
pendicitis. 

Extra-uterine  pregnancy  is  to  be  rec- 
ognized by  the  existence  of  the  usual 
subjective  signs  of  pregnancy,  by  vaginal 
examination,  and  by  the  absence  of  in- 
flammatory symptoms  prior  to  the  rupt- 
ure.    (Annals  of  Surg.,  Mar.,  '98.) 

Etiology  and  General  Characteristics. 
— Young  adults,  especially  males,  consti- 
tute the  majority  of  cases.  Appendicitis 
occurs  at  all  ages,  however,  though  very 
rarely  during  infancy. 

Among  489  cases  found  in  literature 
392  were  males  and  97  females.  Pravaz 
(These  de  Lyon,  '88). 

Of  90  cases,  73  per  cent,  were  under 
thirty  years  of  age;  76  per  cent,  were 
males,  24  per  cent,  females.  Bigelow 
(Vis  Medicatrix,  Oct.,  '91). 

Report  of  517  eases  seen  in  the  leading 
Montreal  hospitals  showing  the  condi- 
tion to  be  most  common  between  the 
ages  of  twenty  and  thirty,  and  to  occur 


twice  as  often  in  males  as  in  females. 
G.  A.  Armstrong  (Lancet,  Sept.  18,  '97). 
Study  of  80  cases  treated  by  Broca; 
70  not  previously  published.  Propor- 
tion of  boys  to  girls,  58  to  21;  5  were 
aged  between  2  and  5,  25  between  5  and 
10,  and  41  between  10  and  15  years. 
:Mlle.  Gordon   (These  de  Paris,  No.  101, 


Heredity  seems  to  act  as  a  predispos- 
ing factor  in  connection  with  an  arthritic 
diathesis. 

Three  cases  in  which  appendicitis 
seemed  to  follow  family  lines.  The  first 
patient  had  lost  a  daughter  one  year 
before  from  peritonitis,  resulting  from 
appendicitis.  She  had  had  three  pre- 
vious attacks.  The  second,  a  child,  11 
years  of  age,  had  a  first  cousin,  12  years 
of  age,  operated  on  for  appendicitis.  The 
third,  a  boy  aged  13  years,  had  lost  an 
elder  brother,  who  had  died  of  general 
peritonitis.  A  gangrenous  appendix  also 
found  in  this  case.  W.  T.  Smith  (Med. 
Record,  Sept.  12,  '96). 

Heredity  as  a  predisposing  cause. 
The  author  refers  to  the  fact  that  for- 
eign writers  have  reported  a  number  of 
families  in  which  this  disease  was  fre- 
quent. Talamon  says  that  the  reason 
this  subject  has  been  overlooked  in 
medicine  is  due  to  the  fact  that  the 
clinical  forms  and  methods  of  treatment 
of  appendicitis  have  been  discussed,  to 
the  neglect  of  the  etiologj'.  The  author 
reports  three  family  histories  in  which 
appendicitis  and  bowel  disturbance  were 
very  common.  In  the  first  family  there 
was  a  train  of  symptoms  going  through 
all  the  members  of  the  second  genera- 
tion. These  refer  to  gastro-intestinal 
disorders  associated  with  nervous  symp- 
toms and  circulatory  disturbance.  In 
the  third  generation  there  was  appen- 
dicitis. In  the  second  family  the  father 
probably  had  appendicitis,  and  he  as 
well  as  the  mother  had  constipation. 
All  the  members  of  the  second  genera- 
tion had  some  gastro-intestinal  disturb- 
ance. Three  of  the  members  of  this 
family  had  appendicitis.  In  the  third 
generation  of  the  same  family  constipa- 
tion  was   the   rule,   and   in   the   fourth 


APPENDICITIS.    ETIOLOGY. 


465 


generation  there  were  two  cases  of  gas- 
trectasis.  F.  Forschheimer  (Amer.  Med., 
Oct.  5,  1901). 

"  he  local  inflammation  may  be  caused 
y^  the  intrusion  of: — 

1.  Micro-organisms,  specific,  and  non- 
specific, of  which  constipation,  dietetic 
indiscretions;  neighboring  catarrhal,  ty- 
phoid, and  tubercular  processes;  constric- 
tion, torsion,  or  strain  are  the  primary 
etiological  factors.  Cases  due  to  actino^ 
mycosis  are  occasionally  observed.  Trau- 
matism, blows  upon  the  abdomen,  etc., 
sometimes  produce  inflammation  of  the 
appendix. 

The  great  frequency  of  this  aflfeotion 
is  due  to  the  fact  that  the  appendi.x  is 
a  funetionless  structure  of  low  vitality, 
removed  from  direct  faecal  current; 
bacterium  coli  commune  is  always 
present  and  is  capable  of  great  virulence 
when  constriction  of  the  appendix  or 
lesions  of  its  mucous  membrane  or  other 
coats  are  present.  J.  William  White 
(Therapeutic  Gazette,  p.  385,  '94;  Brit. 
Med.  Jour.,  Feb.  9,  '95). 

Case  of  appendicitis  due  to  trauma- 
tism, the  patient,  a  boy  of  16  years,  hav- 
ing been  struck  in  the  right  iliac  region 
by  the  handle  of  a  push-cart.  Distinct 
tumor  in  the  right  iliac  region,  marked 
tenderness  moat  acute  over  McBurney's 
point,  and  some  pyrexia.  The  tip  of 
the  appendix  found  gangrenous.  W.  S. 
Coley   {Med.  Record,  Feb.  15,  '96). 

A  strain  may  apparently  originate  an 
attack:  a  point  of  medico-legal  impor- 
tance. An  already  damaged  appendix  is 
especially  susceptible  to  such  injury. 
Many  acute  attacks  of  appendicitis  com- 
mence during  sleep.  Rutherford  Mor- 
ison  (Edinburgh  Med.  Jour.,  Mar.,  Apr., 
May,  '97). 

The  disease  is  of  growing  medico-legal 
importance,  as  many  cases  are  of  trau- 
matic origin,  and  may  therefore  give  rise 
to  proper  suits  for  damage  or  valid  claims 
against  accident-insurance  companies. 
W.  B.  Small  (Med.  Record,  Sept.  10,  '98). 

In  three  hundred  male  and  one  hun- 
dred and  eighteen  female  adult  autop- 

1- 


sies  the  appendix  was  found  so  fre- 
quently adherent  to  the  psoas  muscle 
while  free  from  adhesions  when  situated 
elsewhere  tliat  the  conclusion  that 
trauma  of  the  psoas  muscle  is  most  pro- 
ductive of  appendicitis  is  inevitable. 
Byron  Robinson  (Annals  of  Surg.,  Apr., 
1901). 

Three  cases  showing  that  a  slight  in- 
jury may  give  rise  to  a  fatal  attack  of 
appendicitis,  A  small  deposit  of  hard 
fffical  matter  in  the  appendi.x  may,  after 
prolonged  retention,  set  up  localized 
necrosis,  which  is  not  likely  to  cause 
mischief  so  long  as  it  involves  only  the 
inner  layers  of  the  appendical  wall. 
Any  injury  inflicted  on  the  abdomen 
may  rupture  the  intact  external  coat, 
and  cause  the  infected  contents  of  the 
appendix  to  penetrate  the  abdominal 
cavity.  Direct  or  indirect  traumatism 
may  produce  an  attack  of  appendicitis 
in  a  healthy  subject,  but  in  most  trau- 
matic cases  a  laceration  caused  by  a 
confined  enterolith  is  the  starting-point 
of  the  inflammation.  Schottmuller 
(Mitt,  aus  der  Gren.  der  Med.  und  Chir., 
B.  vi,  H.  1  and  2,  1901);  Neumann 
(Arehiv  f.  klin.  Chir.,  B.  Ixxii,  H.  2). 

2.  Irritating  fsecal  matter,  which  fre- 
quently forms  hard  egg-shaped  fsecal  con- 
cretions of  various  sizes;  foreign  bodies, 
— cherry-stones,  orange-seeds,  buttons, 
spicules  of  bone,  etc., — which  penetrate 
into  the  interior  of  the  appendix  through 
deficient  action  of  a  valve  which  usually 
closes  its  opening,  or  on  account  of  ex- 
cessive patency  of  the  latter.  Grape- 
seeds  were  at  one  time  thought  to  play 
an  important  role  as  etiological  factors, 
but  a  painstaking  investigation  by  Ed- 
mund Andrews  showed  that  this  was  not 
based  on  facts.  Indeed,  it  is  quite  prob- 
able that  foreign  bodies  play  a  very  small 
part  in  the  production  of  attacks  of 
appendicitis,  hardened  faecal  masses  be- 
ing excluded. 

Study  of  four  hundred  specimens  of 
the  vermiform  appendix.  Fsecal  stones 
found   thirty-eight   times;     equally   fre- 


466 


APPENDICITIS.    ETIOLOGY. 


quent  in  both  «exes.  The  appendix  un- 
dergoes a  process  of  retrogression,  in 
length,  in  its  histological  structure,  and 
spontaneous  obliteration  of  the  lumen. 
The  average  length  is  eight  and  one- 
fourth  centimetres;  greatest  length  at- 
tained between  the  ages  of  10  and  30; 
the  shorter  the  appendix,  the  more  fre- 
quent the  obliteration.  Ribbert  (Vir- 
chow's  Archiv,  B.  132,  H.  1,  '93). 

Of  one  hundred  and  forty-six  adult 
eases  recorded  by  Matterstock  sixty- 
three  had  faecal  concretions  and  but  nine 
had  foreign  bodies.  J.  0.  Affleck  (Int. 
Med.  Mag.,  Oct.,  '93). 

Two  hundred  cases  of  appendicitis  ex- 
amined for  seeds.  In  one  case  a  few 
strawberry-seeds  found,  while  none  of 
the  others  contained  more  than  a  fsecal 
concretion  in  the  form  of  a  foreign  body. 
Gallant  (Med.  Record,  Feb.  15,  '96). 

Investigation  as  to  the  question  of  the 
part  played  by  grape-seeds  in  the  eti- 
ology of  appendicitis,  based  upon  all 
cases  found  in  the  Chicago  hospitals  dur- 
ing a  period  of  fourteen  years:  3709  in 
number.  Instead  of  finding  that  a  large 
number  of  eases  had  occurred  during 
August,  September,  October,  and  No- 
vember,— the  grape-eating  months, — it 
was  actually  found  that  a  smaller  num- 
ber of  cases  had  been  observed  during 
these  months  each  year.  Edmund  An- 
drews (Jour.  Amer.  Med.  Assoc,  vol. 
xxvii,  p.  1193,  '96). 

Appendicitis  caused  by  a  full-sized 
Asoaris  lumbricoides  in  the  appendix. 
J.  Price  (Va.  Med.  Semimonthly,  Jan. 
29,  '98). 

The  vermiform  appendix  is  a  common 
habitat  of  thread-worms;  very  probably 
they  breed  there.  In  200  autopsies  on 
children  under  twelve  years  of  age 
thread-worms  were  present  in  the  intes- 
tines in  38,  or  19  per  cent.,  and  in  those 
children  over  twelve  years  of  age  the 
percentage  was  much  higher,  viz.:  32 
per  cent.  In  no  less  than  25  out  of  the 
38  cases  the  worms  were  found  in  the 
appendix,  and  in  6  the  appendix  was  the 
only  part  of  the  alimentary  canal  where 
the  worms  were  found.  In  1  case  where 
pain  had  been  complained  of  in  the  right 
iliac  fossa  the  appendix  contained  HI 
worms,  and  was  in  a  catarrhal  condition. 


In  several  other  cases  the  appendix  was 
in  a  similar  condition.  The  idea  that 
thread-worms  are  chiefly  found  in  the 
lower  part  of  the  colon  is  therefore  erro- 
neous, and  injections,  in  order  to  be 
effective,  must  be  sufficiently  bulky  to 
reach  the  caecum,  as  much  as  16  to  20 
ounces  being  often  tolerated  by  children 
of  from  six  to  twelve  years  of  age.  Still 
(Brit.  Med.  Jour.,  vol.  i,  p.  898,  '99). 

One  thousand  four  hundred  cases  col- 
lected from  various  sources  in  the  last 
ten  years,  and  only  about  7  per  cent, 
found  of  true  foreign  bodies.  In  700  of 
these  cases  in  which  definite  statement 
was  made  as  to  the  nature  of  the  for- 
eign bodies,  45  per  cent,  were  fsecal  con- 
cretions. The  only  foreign  body  observed 
in  250  cases  of  appendicitis  at  the  Johns 
Hopkins  Hospital  was  a  segment  of  a 
tape- worm.  J.  F.  Mitchell  (Johns  Hop- 
kins Hosp.  Bull.,  Jan.,  Feb.,  Mar.,  '99). 

As  previously  shown,  appendicitis 
may  be  caused  by  ova  of  the  ascaris. 
lumbricoides  and  trichocephalus  dispar. 
This  view  sustained  by  five  other  eases. 
Hence,  in  all  cases  of  appendicitis  the- 
stools  should  be  examined  for  worms  or 
their  ova.  When  possible,  santonin  and 
thymol  should  be  given.  Raw  veg- 
etables, salads,  strawberries,  etc.,  and 
unboiled  or  unfiltered  water  should  b& 
prohibited  those  with  appendicitis,  or 
subject  to  it,  and  their  stools  examined 
from  time  to  time.  Metehnikoff  (Jour, 
des  Prat.,  Mar.  23,  1901). 

Notwithstanding  the  frequency  of 
worms  (ascarides  and  triehocephali) 
among  the  Chinese  and  Europeans  liv- 
ing in  China,  not  a  single  case  of  ap- 
pendicitis met  with  in  the  European 
population,  some  120  persons,  under  per- 
sonal care.  Yet  in  a  young  Russian 
woman  and  in  two  missionaries  abdom- 
inal pains  suggesting  appendicular  colic 
seemed  to  depend  on  the  presence  of  a 
taenia;  they  ceased  on  the  expulsion 
of  the  parasite.  The  rarity  of  appendi- 
citis in  the  Chinese  appears  to  confirm 
the  opinion  of  Keen  and  Lucas-Cham- 
pionni&re  as  to  the  predisposing  influ- 
ence of  meat  diet,  meat  in  China  being 
a  luxury  within  the  reach  of  few. 
Matignon  (Bull,  de  I'Acad.  de  MSd.^ 
Mar.  26,  1901). 


APPENDICITIS.     GENERAL  PATHOGENESIS. 


467 


General  Pathogenesis.  —  The  vermi- 
form appendix  is  a  glandular  organ  pre- 
senting a  certain  analogy  to  the  tonsils 
and  liable,  as  well,  to  follicular,  mucous, 
submucous,  infectious,  exudative,  and 
ulcerative  disorders. 

The  appendix  is  rather  a  glandular 
organ  than  an  organ  of  absorption;  its 
mucous  glands  and  lymphoid  tissue  are 
greatly  developed.  In  the  angle  formed 
by  the  appendix,  the  cfecuni,  and  the 
small  intestine  there  is  a  lymphatic  gan- 
glion not  before  described.  Clado  (Bull, 
de  la  Soc.  de  Biol,  Jan.  30,  '92). 

Like  the  tonsil,  the  appendix  abounds 
in  closed  adenoid  follicles,  and,  like  ton- 
sillitis, appendicitis  recurs  in  patients 
who  are  predisposed  to  it.  Since  ton- 
sillitis is  one  of  the  most  frequent  mani- 
festations of  influenza  due  to  a  change 
in  the  seasons,  it  is  not  to  be  wondered 
at  that  appendicitis  should  occur  under 
the  same  conditions.  Three  illustrative 
cases.  P.  Merklen  (Univ.  Med.  Jour., 
Apr.,  '97). 

An  absolutely  healthy  appendix  is 
never  attacked  by  appendicitis,  but  may 
become  involved  by  continuity  from 
catarrhal  inflammation  of  the  cteoum. 
Appendicitis  has  always  a  gi-adual  begin- 
ning without  symptoms,  followed  by 
signs  of  sudden  acute  inflammation.  A 
pointed  foreign  body  in  the  appendix 
may  give  similar  symptoms  rapidly  fol- 
lowed by  perforation.  The  appendix  is 
predisposed  to  attacks  by  chronic  ill- 
ness. While  ftecal  concretions  are 
usually  found  in  a  healthy  appendix, 
they  may  occur  in  granular  or  tuber- 
cular appendicitis.  Stricture  or  stenosis 
of  the  appendix  may  occur.  Non-puru- 
lent appendicitis  rarely  contains  a  fsecal 
concretion.  Gangrene  occurs  earlier  in 
purulent  than  non-purulent  appendi- 
citis; gangrene  is  more  rare  with  strict- 
ure or  stenosis  of  the  appendix  than 
with  granular  appendicitis.  Minute 
haemorrhages  occur  and  the  infection 
reaches  the  lymph-channels.  Periap- 
pendicular abscess  may  develop  without 
perforation,  rarely  even  at  some  dis- 
tance from  the  appendix,  and  may  be 
wholly    absorbed,   with   recovery.      Ste- 


nosis of  the  appendix  rarely  heals  spon- 
taneously, and  the  presence  of  a  con- 
cretion usually  causes  suppuration, 
though  it  may  reach  the  ca>cum.  Only 
about  one-third  of  all  cases  run  a  mild 
course.  Of  282  patients  with  appendi- 
citis, but  84  were  non-purulent.  Riedel 
(Archiv  f.  klin.  Chir.,  vol.  Ixvi,  Nos.  3 
and  2,  1902). 

An  appendicular  inflammatory  proc- 
ess is  almost  invariably  started  by  the 
bacillus  coli  communis.  In  a  certain 
proportion  of  cases  other  micro-organ- 
isms, especially  the  staphylococcus  py- 
ogenes and  streptococcus,  are  also  found. 

Experiments  in  rabbits  showing  that. 
any  obstruction  of  the  mouth  of  the  ap- 
pendix is  sufficient  to  cause  appendicitis. 
The  bacillus  coli  found  in  pure  culture 
remain  inoffensive  until  obstruction  of 
the  opening  causes  their  multiplication. 
Roger  and  Josu6  (Jour,  des  Practiciens^ 
Feb.  8,  '96). 

The  coli  bacillus,  undoubtedly,  may 
alone  exist  in  the  exudate.  In  20  cases 
examined,  all  purulent,  10  were  asso- 
ciated Avith  other  bacteria,  the  most  im- 
portant of  which  in  6  cases  was  the 
streptococcus.  It  is  probable  that  ia 
appendicitis  the  coli  bacillus  is  aided 
by  other  bacteria,  which  it  soon  out- 
numbers and  destroys.  Achard  and 
Broca  (Gaz.  Heb.  de  M6d.  et  de  Chir., 
Apr.  1,  '97). 

New  method  of  studying  the  removed 
appendix.  Within  a  few  hours  after  re- 
moval the  appendix  should  be  distended 
with  95-per-eent.  alcohol,  through  a  con- 
ical nozzle  of  a  small  syringe  tied  tightly 
into  its  cut  end  by  a  ligature,  which  is 
tightened  as  the  syringe  is  withdrawn. 
The  distended  organ  is  then  immersed 
twenty-four  hours  or  more  in  alcohol  of 
the  same  strength.  It  is  then  ready  for 
section.  If  it  is  sliced  centrally  from 
end  to  end,  its  interior  will  be  a  revela- 
tion to  the  surgeon.  Whereas  the  out- 
side may  preserve  the  cylindrical  form 
of  a  normal  appendix,  and  may  give 
little  or  no  evidence  of  inflammation, 
the  interior   (if  the  patient  has  had  one 


468 


APPENDICITIS.     GENERAL  PATHOGENESIS. 


or  more  attacks)  will  show  one  or  sev- 
eral of  the  conditions  illustrated  by  the 
annexed  cuts.  Robert  Abbe  (Med.  Rec- 
ord, July  10,  '97). 

Histological  study  of  the  various  forms 
of  follicular  appendicitis:     I.   Recurrent 


formed  from  the  faeces  and  contain  no 
food-remnants,  they  are  derived  from  the 
mucous  secretion  of  Lieberkiihn's  glands; 
the  latter  are  hypertrophied  from  their 
activity.  3.  The  obliteration  of  the 
vermiform  process  is  a  pathological  proe- 


7  "  "  10 

Figs.  1,  2,  and  3. — A  fsecal  concretion  blocking  the  canal. 
Figs.  4,  5,  and  6. — Interior  ulcerations. 

Figs.  7,  8,  and  9. — Cicatricial  strictures,  often  of  pin-hole  aperture  only. 
Fig.  10. — Multiple  strictures  with  intermediate  pockets,  containing  suppurating  and 

catarrhal  products  and  confined  by  greatly  hypertrophied  muscular  and  mucous 

coats. 
Fig.  11. — Partial  obliterating  appendicitis. 
These  five  varieties  are  subject  to  minute  variations.     {Robert  Abbe.) 


appendicitis  has  its  principal  location  in 
the  follicles.  2.  Fseeal  concretions,  which 
are  frequently  found  in  appendicitis,  are 
a  result  of  the  appendicitis ;    they  are  not 


ess  Avhieh  follows  follicular  appendicitis. 
4.  Gangrenous  appendicitis  in  which  all 
the  coats  of  the  organ  are  destroyed 
simultaneously  is  fortunately  of  rare  oc- 


APPENDICITIS.     GENERAL  PATHOGENESIS. 


469 


currence.     Pilliet    (Le   Prog.   Med.,  Jan. 
29, '98). 

There  are  at  least  four  distinct  vari- 
eties of  appendicitis  obliterans:  an  exu- 
dative variety;  a  variety  characterized 
by  mucosal  hyperplasia,  and  sclerosis;  a 
variety  characterized  by  submucous  hy- 
pertrophy;   a  reparative  variety.     In  all 


U-shaped  appendix  with  central  constriction. 
Lower  segment  found  empty.     (Brun.) 

(I.a  Pr9bScMc<li<;iile  ) 

varieties  there  may  be  and  generally  is 
localized  peritonitis;  endarteritis  and 
periarteritis  are  almost  constant  phe- 
nomena in  the  disease.  The  vermifonn 
appendix,  in  health,  is  distinctly  muscu- 
lar; in  disease  the  muscles  often  hyper- 
trophy. J.  F.  Binnie  (Annals  of  Surg., 
May,  '98). 

Appendicitis  should  be  regarded  as  an 
inflammation  of  the  vermiform  process 
due  to  infection.  The  streptococcus 
lanceolatus,  the  bacillus  pyogenes,  the 
bacillus  subtilis,  the  staphylococci,  the 
bacterium  coli  commune  may  each  be 
responsible  for  the  infection,  but  in  the 
large  majority  of  instances  the  culture 
will  be  found  to  contain  either  the  bac- 
terium coli  commune  alone  or  in  con- 
junction with  one  of  the  other  afore- 
mentioned organisms.  It  is  a  well- 
known  fact  that  these  organisms  may 
exist  in  the  intestinal  tract  without  pro- 
voking infection,  but  that  when  there  is 
any  circulatory  disturbance  or  injury  to 
the  mucous  membrane  their  virulence  in- 
creases, and  infection  is  apt  to  follow. 
Carl  Beck  (N.  Y.  Med.  Jour.,  Nov.  19, 
'98). 

Virulence  of  the  bacillus  coli  in  experi- 


mental appendicitis.  Increased  virulence 
of  the  B.  coli  and  appendicitis  can  occur 
without  occlusion  of  the  cavity  of  the 
appendix;  suppurative  appendicitis  can 
occur  as  a  result  of  nutritional  changes 
in  the  appendicular  parietes,  and  this 
without  an  increased  virulence  of  the  B. 
coli  contained  in  the  pus.  Charles  de 
Klecki  (Ann.  de  I'lnstitut  Pasteur,  June 
25,  '99). 

Of  all  the  etiological  factors  that  enter 
into  the  pathogenesis  of  appendicitis,  im- 
perfect drainage  of  the  organ  plays  the 
most  conspicuous  part.  Whenever  this 
is  present,  and  exists  for  only  a  brief 
period  of  time,  there  are  bound  to  arise 
very  definite  and  at  times  serious  conse- 
quences. As  a  result  of  the  interference 
with  drainage,  the  bacillus  coli  communis 
is  changed  into  a  virulent  organism. 
Next  in  importance  to  the  part  played 
by  insufficient  drainage  and  increased  ac- 
tivity of  micro-organisms  is  the  question 
of  circulatory  disturbances.  The  insig- 
nificance attached  to  the  presence  of 
foreign  bodies   in    the   human   appendix 


Cystic  appendices  with  thin  walls  and  filled 
with  sero-purulent  fluid,  but  having  open, 
though  small,  canals.     (Bnm.) 

lL:i  Pre.sse  Medicalo.) 

was  well  borne  out  by  the  experimental 
work.  C.  H.  Frazier  (William  Pepper 
Laboratory  of  Clin.  Med.,  1900;  Medi- 
cine, Aug.,  1900). 

Appendicitis  almost  always  precedes- 
an  attack  of  perityphlitis  or  paratyphli- 
tis. 


470 


APPENDICITIS.     PATHOLOGY  OF  VARIOUS  FORMS. 


Records  of  one  hundred  post-mortem 
examinations,  91  per  cent,  of  which 
showed  that  the  disease  had  started  in 
the  vermiform  appendix.  Primary  per- 
foration of  the  caeeum  was  observed  in 
only  9  per  cent,  of  the  cases.  Einhorn 
(Miinchener  med.  Woch.,  Xos.  7  and  S, 
'91). 

The  affection  may  start  either  in  the 
caecum  or  the  appendix,  but  with  marked 
predilection  for  the  latter.  Herman 
Mynter  (Deutsche  med.  Woch.,  Apr., 
'91). 

In  three  hundred  and  twenty-four 
cases  the  appendix  was  found  to  be  the 
seat  of  the  disease  two  hundred  and 
eighty-two  times.  The  importance  of  the 
appendix  as  a  starting-point  for  disease 
is  beyond  dispute.  Hartley  (X.  Y.  Med. 
Jour.,  June  25,  '92). 

Post-mortem  records  at  Municli  fully 
bear  out  the  generally  received  idea 
that  the  appendix  is  primarily  involved. 
Haenel  (Miinchener  med.  Woch.,  Mar. 
26,  '95). 

Pathology  of  Various  Forms.  —  The 

simple  catarrhal  form  is  usually  caused 
by  constipation  or  indiscretion  in  diet, 
in  which  the  inflammatory  process,  after 
passing  through  an  acute  stage,  includ- 
ing more  or  less  epithelial  desquamation, 
excoriation,  etc.,  and  involving  the  mu- 
cosa, submucosa,  and  the  serous  layer 
and  the  overlying  area  of  peritoneum, 
gradually  recedes.  The  appendix  re- 
mains very  vascular  and  functionally 
weakened,  and  is  subject  to  renewed 
attacks  of  inflammation. 

The  ulcerative  form,  in  which  the  in- 
flammation is  usually  produced  by  fscal 
concretions  or  foreign  bodies,  gradually 
proceeds  to  ulceration.  An  opening  be- 
comes formed  near  the  apex  of  the  organ 
and  the  f^cal  concretion  or  foreign  body 
escapes,  with  the  septic  discharges 
formed,  into  the  abdominal  cavity. 

The  majority  of  primary  attacks  of 
appendicitis  occur  through  an  eroded 
mucous  membrane,  caused  by  masses  of 
faecal  matter,  rarely  by  a  foreign  body. 


Faecal  matter  is  introduced  into  the 
lumen  of  the  appendix  by  contractions 
of  the  caecum.  The  expulsive  force  of 
the  appendix  is  not  sufficient  to  expel 
it,  and  hence  it  remains  to  ii-ritate  the 
mucous  layer,  at  first  merely  by  its 
presence.  The  slight  muscular  move- 
ments of  the  appendix  tend  to  mold 
the  mass  into  a  round  or  oblong  shape. 
This  mass  is  augmented  by  the  natural 
secretions  of  tlie  mucous  membrane  of 
the  appendix  and  by  further  accessions 
of  faecal  matter  from  the  caecum.  Grad- 
ually tlie  concretion  increases  in  size 
until  it  irritates  by  causing  pressure 
against  the  walls  of  the  organ.  This  is 
followed  by  a  decided  erosion  of  the  mu- 
cous membrane,  and  this  by  an  invasion 
of  the  micro-organisms  which  are  always 
present  in  faecal  matter.  They  prolif- 
erate, and  the  inflammatory  troubles 
tlien  begin.  In  a  few  cases  the  increased 
secretion  of  tlie  mucous  layer  may  cause 
partial  liquefaction  of  the  faecal  con- 
cretion, which  may  be  expelled.  In  the 
majority  of  cases,  however,  the  concre- 
tion remains  in  the  lumen,  where  it  is 
found  to  act  as  an  exciting  cause  of 
furtlier  inflammatory  trouble.  J.  B. 
Deaver  (Amer.  Jour.  Med.  Sciences,  Aug., 
'97). 

Anything  that  could  remove  the  epi- 
thelial lining  from  the  mucous  membrane 
of  the  appendix  miglit  be  the  starting- 
point  of  the  mischief.  6.  A.  Armstrong 
(Lancet,  Sept.  18,  '97). 

The  idea  embodied  in  the  word  ca- 
tarrhal appendicitis  is  a  correct  one  in 
tlie  very  early  stages  in  the  morbid  con- 
dition. Excluding  the  rarer  cases  when 
foreign  bodies  are  entrapped,  or  in  which 
there  is  kinking  of  the  appendix  from 
its  short  mesentery,  the  origin  of  the 
stricture  is  found  in  one  of  two  causes: 
septic  and  linear  ulcer  or  the  contrac- 
tion of  the  catarrhal  inflammation, 
antedating  this  stricture  by  many 
years.  From  this  study  it  may  be  said 
with  certainty  that  the  first  attack  of 
appendicitis  recognized  by  the  patient 
is  in  most  eases  the  end  of  the  disease, 
for  the  appendix  sliows  the  presence  of 
a  stricture  which  may  have  existed  for 
many  years.  The  most  complete  experi- 
ence clinicallv  of  the  variations  in  the 


APPENDICITIS.    PATHOLOGY  OF  VARIOUS  FORMS. 


471 


symptoms  is  often  required  to  differ- 
entiate between  the  disease  in  question 
and  so  unlike  a  malady  as  typhoid 
fever.  The  latter  study  of  leucocytosis 
throws  much  light  upon  the  differential 
diagnosis.  Attacks  may  often  be  cured 
by  natural  methods;  that  a  long  re- 
spite does  not  mean  a  cure,  and  that 
it  is  impossible  to  predict  a  cure;  and, 
finally,  that,  unless  the  appendix  is  re- 
moved, the  disease  is  always  latent 
where  once  it  is  begun.  Robert  Abbe 
(Med.  Record,  Feb.  16,  1901;  Phila.  Med. 
Jour.,  Feb.  23,   1901). 

The  following  classification  proposed: 

Acute  Appendicitis. 

First    Catarrhal. 

Second    Interstitial. 

Third Ulcerative. 

Fourth    Gangrenous. 

Cheonic  Appendicitis. 

First Catarrhal. 

Second     Interstitial. 

Third  Obliterating. 

The  appendix  is  the  most  vulnerable 
of  the  abdominal  organs  because  of  its 
deficient  blood-,  nerve-,  and  lymphatic 
supply,  its  length  and  calibre,  and  be- 
cause of  its  liability  to  traiunatism  in 
its  association  with  the  psoas  muscle. 
The  majority  of  cases  are  of  a  chronic 
nature,  and  not  infrequently  the  whole 
pathology  of  appendicitis  is  demon- 
strated in  one  patient.  Obliteration  of 
the  lumen  of  the  appendix  is  rare  and 
never  to  be  relied  upon.  The  rapidity 
and  suddenness  with  which  the  organ 
may  become  diseased  and  gangrenous, 
giving  rise  to  a  fatal  peritonitis,  empha- 
sized. 

The  three  principal  symptoms  are 
pain,  tenderness,  and  rigidity.  The 
most  important  of  these,  pain,  is  parox- 
ysmal, and  may,  at  intervals,  almost  dis- 
appear. Its  location  entirely  depends 
upon  the  position  of  the  appendix.  It 
is  well  to  always  palpate  at  a  point 
some  distance  from  the  supposed  seat 
of  disease  and  then  gradually  approach 
the  point  of  tenderness.  Abrupt  cessa- 
tion of  pain  implies  gangrene.  Both 
temperature  and  blood-count  are  of 
little  value  as  diagnostic  signs.     J.  B. 


Deaver   (Jour.  Amer.  Med.  Assoc.,  July 
13,  1901). 

In  one  hundred  and  forty-six  cases 
collected  by  Matterstock  perforation  was 
found  to  have  occurred  one  hundred  and 
thirty-two  times. 

The  complications  following  perfora- 
tion vary.  Normally  the  peritoneum 
completely  surrounds  the  appendix  and 
the  esecum,  and  a  localized  peritonitis 
and  a  perityphlitic  abscess  necessarily 
follow. 

If,  however,  through  previous  local  in- 
flammation, close  adhesions  have  united 
the  appendix  and  the  peritoneum,  both 
organs  are  perforated  simultaneously, 
and  the  appendical  contents  may  pass 
entirely  through  the  peritoneal  coats. 
This  gives  rise  to  an  extraperitoneal 
abscess,  which  may  open  externally 
above  Poupart's  ligament  or  within  the 
abdomen  into  the  small  intestine,  the 
bladder,  the  vagina  or  the  rectum,  the 
portal  vein,  the  iliac  artery,  etc. 

Infection  of  the  retroperitoneal 
glands  and  lymphatics  and  of  the  portal 
vein  is  much  more  frequent  than  is  gen- 
erally believed,  and  leads  to  perirenal 
abscess  and  sinuses  in  the  loin  or  groin. 
When  a  case  in  which  good  drainage  has 
been  secured  shows  a  persistent  eleva- 
tion of  temperature,  this  complication 
should  be  thought  of  if  the  chest,  kid- 
nej'S,  and  pelvic  organs  can  be  excluded. 
Portal  infection,  with  tenderness,  jaun- 
dice, and  general  malaise,  usually  calls 
for  operation.  Hepatic  tenderness  and 
sepsis  imply  a  possible  portal  phlebitis. 
Mild  infections  both  of  the  lymphatics 
and  of  the  portal  system  occasionally 
yield  to  medical  treatment.  Persistent 
fever,  without  other  evident  cause, 
should  suggest  one  or  both  of  these  in- 
fections. Drainage  in  the  loin  gives 
prompt  and  satisfactory  relief,  even 
where  pus  or  a  diffuse  cellulitis  has 
formed.  Prompt  and  thorough  drainage 
of  the  liver,  together  with  the  removal 
of  the  inflamed  appendix,  offers  the  best 
means  of  recovery  from  septic  infections 


472 


APPENDICITIS.    PATHOLOGY  OF  VARIOUS  FORMS. 


of  the  liver.  Aspiration  of  the  liver  is 
an  imperfect  procedure.  Abdominal  sec- 
tion with  free  exploration  and  free 
opening  of  all  abscesses  within  reach  is 
less  dangerous  and  much  more  satisfac- 
tory. J.  V.  Munro  (Therap.  Gaz.,  Jan. 
15,  1901). 

Two  cases  complicated  with  phlebitis 
of  the  left  leg.  In  one  case  pain  in  the 
left  leg  occurred  the  second  day,  fol- 
lowed by  dyspnoea  and  fever  on  the 
third.  A  day  later  marked  phlebitis 
appeared.  Cough  with  bloody  expecto- 
ration followed,  with  all  the  signs  of  a 
pulmonary  infarct.  The  second  case 
was  one  of  purulent  appendicitis  and 
phlebitis.  Two  other  cases  referred  to. 
Of  the  four,  two  died.  A  peculiarity  is 
that  it  occurs  more  frequently  on  the 
left  side.  It  is  evidently  due  to  metas- 
tasis through  the  circulation.  Its  oc- 
currence makes  the  prognosis  unfavor- 
able. Villard  and  Vignard  (Revue  de 
Chir.,  Jan.,  1901). 

Two  cases  of  thrombosis  of  the  fem- 
oral veins  following  appendectomy.  Ex- 
cessive pain  in  the  left  groin,  followed 
a  few  days  later  by  oedema  of  the  leg 
and  the  infiltrated  vein,  were  the  main 
signs.  Infection  is  probably  the  causa- 
tive factor  of  this  complication  rather 
than  the  mechanical  theory  of  Lennan- 
der.  W.  Meyer  (Annals  of  Surg.,  May, 
1901). 

Pleurisy,  due  to  propagation  of  the  in- 
flammation through  the  retroperitoneal 
cellular  tissue,  or  through  the  lymphatic 
system,  is  an  occasional  complication,  but 
often  passes  unperceived.  It  is  almost 
invariably  on  the  right  side,  and  is  rarely 
bilateral. 

Pleurisy  observed  34  times  in  89  cases. 
In  the  34  cases  but  1  presented  the  com- 
plication on  the  left  side.  When  bilateral 
pleurisy  does  present  itself  the  right 
pleura  is  the  first  affected  and  contains 
the  largest  effusion.  Wolbrecht  (These 
de  Lyon,  '93). 

Out  of  45  cases  recorded  3  were  of  the 
dry  form,  in  29  the  effusion  was  serous, 
while  in  13  the  liquid  was  purulent,  Avith 
marked  dyspnoea  and  intense  fever.  The 
prognosis    of    the    appendicitis    is    only 


affected  by  the  pysemic  form  of  pleurisy, 
the  serous  form  frequently  disappearing 
of  its  own  accord.  The  lungs  should  be 
carefully  watched  in  all  cases,  therefore, 
lest  the  aggravated  pleurisy  intervene 
to  serously  compromise  the  result. 
Croizet   (These  de  Lyon,  '93). 

Pleurisy  is  generally  a  local  complica- 
tion, a  pleural  abscess  by  contiguity. 
While  metastatic  pleurisy  may  coincide 
with  infarct  on  either  side,  the  latter 
will  be  upon  the  right  side  always,  pre- 
ceded and  accompanied  by  subphrenic 
suppuration.  In  13  cases  from  the  liter- 
ature, right-sided  pleurisy  was  found 
post-mortem  with  subphrenic  abscess, 
showing  the  extension  from  the  appen- 
dix through  the  diaphragm  into  the 
pleura.  The  physical  signs  simulate 
purulent  pleurisy.  The  prognosis  is 
grave;  the  diagnosis  always  diffieult. 
L.  Lapeyre  (Revue  de  Chir.,  May,  1901). 

If  there  is  no  adhesion  between  the 
appendix  and  the  peritoneum  suppura- 
tive peritonitis  is  produced,  and  this 
process  usually  gives  rise  to  a  protective 
plastic  exudation,  which  causes  the  sur- 
rounding loops  of  small  intestine  to  ad- 
here together  and  inclose  the  secondary 
abscess,  thus  temporarily  protecting  the 
surrounding  parts. 

If,  however,  the  plastic  inflammation 
does  not  induce  protective  adhesion  be- 
tween the  intestinal  loops,  the  septic 
material  invades  the  whole  peritoneal 
cavity,  and  gives  rise  to  diffuse  and  fatal 
peritonitis. 

Case  of  appendicitis  complicated  by 
acute  parenchymatous  nephritis.  Prob- 
ably due  to  fact  that  the  toxins  gener- 
ated by  the  virulent  coli  communis  irri- 
tate the  renal  epithelium.  Moldavski 
(Vratch,  May  12,  1901). 

Forty-five  cases  of  subphrenic  abscess 
as  a  complication  of  appendicitis  col- 
lected from  literature  and  personal  case 
show  that  the  complication  is  a  very 
rare  one  and  that  many  were  not  diag- 
nosed until  after  the  death  of  the  pa- 
tient.   It  may  be  extraperitoneal  or  in- 


APPENDICITIS.    PKOGNOSIS. 


473 


traperitoneal.      J.   McF.    Gaston    (Med. 
Record,  Mar.  23,  1901). 

When  appendicitis  is  protracted,  a 
faecal  fistula  often  results.  In  one  of 
three  fatal  cases  of  perforation  of  the 
ctecum  following  appendicitis,  fiEcal  mat- 
ter escaped  and  formed  a  circumscribed 
peritoneal  abscess,  between  the  folds  of 
the  small  intestine.  In  the  other  two 
perforation  occurred  in  the  esecum,  cir- 
cumscribed abscesses  being  also  found. 
When  appendicitis  is  protracted,  the 
mesenteric  glands  swell  and  peritonitis 
may  follow.  As  ftecal  matter  may  enter 
the  peritoneum,  an  early  laparotomy 
will  be  necessary.  E.  Rose  (Deutsche 
Zeit.  f.  Chir.,  Feb.,  1901). 

Prognosis.  —  Death  may  occur  very 
early,  especially  in  children,  who  are  also 
more  liahle  to  peritonitis  than  adults. 
The  danger  of  death  is  greater  in  men 
than  in  women. 

It  is  in  the  first  twenty-four  hours 
from  the  beginning  of  the  attack  that 
we  can  decide  not  only  as  to  the  diag- 
nosis, but  as  to  the  probable  course  and 
result  of  the  case.  If  in  five  or  six  hours 
there  is  no  increase  in  urgency,  the  pa- 
tient is  not  in  immediate  danger,  kept 
at  perfect  rest  in  bed ;  if  in  twelve  hours 
there  is  still  no  increase  in  the  severity 
of  the  symptoms,  the  patient  should 
soon  begin  to  improve.  If  the  urgency 
of  the  case  has  steadily  increased  in 
twelve  hours  from  the  time  when  the 
diagnosis  was  made,  an  operation  will 
probably  be  called  for.  After  two  at- 
tacks a  patient  is  sure  to  have  a  third, 
and  each  attack  renders  operation  more 
difficult  and  dangerous.  All  the  advan- 
tages lie  with  operation  between  the 
attacks.  In  an  operation  during  an 
acute  attack  the  prognosis  is  worse. 
McBurney   (Med.  News,  No.  24,  '96). 

Conclusions  based  on  213  personal 
cases: — 

1.  Cases  with  early  fever  (104°  F.), 
with  defervescence  on  third  or  fourth 
day,  recovered  rapidly. 

2.  Similar  onset,  but  more  prolonged 
fever,  with  fall  of  temperature  about  the 
fifth  day  to  102°  F.  Of  14  cases,  3  were 
operated  on  for  abscess  and  all  cured. 


3.  Temperature  after  fifth  day  still 
over  102°  F.:  infection  virulent  and 
prognosis  unfavorable.  Of  II  such  cases 
2  died,  2  were  cured  without  operation, 
4  were  operated  on,  and  3  recovered  after 
long  illness  due  to  perforation  into  the 
bowel. 

4.  Recurrence  of  fever  after  early  de- 
fervescence. Of  6  such  cases  4  were  oper- 
ated on;    1  died  from  peritonitis. 

5.  General  peritonitis,  with  serious  in- 
fection, low  temperature.  In  these  cases 
the  state  of  the  pulse  gives  indications 
as  to  the  severity  of  the  disease.  J. 
Rotter   (Centralb.  f.  Chir.,  Oct.  24,  '96). 

Reference  made  to  32  cases  of  appendi- 
citis during  and  after  pregnancy,  4  of 
which  were  personal.  In  the  32  cases 
there  were  10  deaths,  a  percentage  of 
31,  which  is  much  higher  than  that  of 
Armstrong  in  his  series  of  517  cases,  with 
a  mortality  of  12.8  per  cent.  The  only 
complication  of  importance  in  appendi- 
citis occurring  during  pregnancy  is  abor- 
tion, noted  in  40  per  cent. ;  this  accounts 
for  fact  that  in  half  the  32  cases  the  chil- 
dren died.  Appendicitis  during  preg- 
nancy should  be  treated  like  ordinary 
appendicitis.  Vinay  (Lyon  MSd.,  Jan. 
2,  '98). 

The  gravity  of  appendicitis  is  consider- 
ably increased  when  that  disease  is  com- 
plicated by  pregnancy.  One  author  esti- 
mates the  mortality  of  appendicitis  dur- 
ing pregnancy  at  31.2  per  cent,  and  that 
of  appendicitis  in  general  at  12.8.  Bu6 
(La  Med.  Mod.,  Mar.  12,  '98). 

The  prognosis  depends  upon  the  chai'- 
acter  of  any  given  case,  whether  it  be 
one  of  the  appendix  perforating  into  the 
general  peritoneal  cavity  or  perforating 
with  limiting  adhesions;  or,  again, 
whether  the  appendix  remains  without 
perforation;  but  chiefly  the  prognosis 
depends  upon  the  stage  at  which  the 
disease  is  seen  and  recognized,  and  upon 
the  treatment  adopted.  If  the  case 
belong  to  either  group  of  the  perforat- 
ing class,  is  seen  within  six,  eight,  or 
twelve  hours  from  the  occurrence  of 
perforation,  and  proper  treatment  is 
adopted,  the  prognosis  is  good.  If  the 
case  is  a  non-perforating  one,  is  seen 
early,  and  appropriate  treatment  is  car- 
ried   out,    the    prognosis    is    excellent. 


474 


APPENDICITIS.    PROGNOSIS. 


On  the  other  hand,  if  two  or  more  days 
have  elapsed  since  perforation  of  the 
appendix  into  the  general  peritoneal 
cavity,  and  as  a  con.sequenee  general 
septic  peritonitis  has  existed  for  this 
length  of  time,  with  general  septicaemia 
as  an  inevitable  result,  death  will  occur 
in  a  large  proportion  of  such  cases  as 
long  as  there  are  no  more  potent  means 
of  treatment  than  are  known  at  the 
present  time. 

In  the  class  of  cases  which  are  treated 
in  the  interim,  again,  the  prognosis  is 
excellent.     J.  C.  Davie   (Dominion  Med. 
Monthly,  Nov.,  1901). 
Improved  methods  of  treatment,  espe- 
cially the  early  evacuation  of  pus  and  a 
better  understanding  of  the  symptoms, 
have  brought  the  mortality  down  from 
30  per  cent,  to  8  per  cent. 

Statistics  of  four  hundred  and  fifty 
reported  operations  during  the  interval 
between  the  attacks  showing  eight 
deaths,  which  would  give  a  mortality 
percentage  of  1.77.  If  all  cases  were 
reported,  5  or  6  per  cent,  would  be  a 
fairer  estimate.  We  need  more  carefully 
recorded  cases.  Bull  (N.  Y.  Med.  Rec- 
ord, Mar.  31,  '94). 

The  surgical  death-rate  in  acute  and 
chronic  appendiceal  cases,  without  ab- 
scess, is  a  fraction  of  I  per  cent,  at  the 
hands  of  several  American  surgeons,  and 
it  is  believed  from  classified  data  that 
the  eventual  death-rate  in  appendicitis 
cannot  be  much  less  than  twenty-five 
per  cent.  The  loss  of  time  and  sufferings 
are  also  much  less  under  proper  surgical 
treatment  than  under  the  best  medical 
treatment.  Robert  T.  Morris  (Med. 
Times,  Apr.,  '98). 

Seven  hundred  and  fifty  oases  of  ap- 
pendicitis personally  observed  show  that 
out  of  464  acute  oases,  284  were  oper- 
ated on,  with  63  deaths,  giving  a  mor- 
tality of  21  per  cent.;  149  cases  recovered 
without  operation,  and  31  cases  were 
moribund  when  first  seen  by  the  surgeon. 

One  hundred  and  fifty-one  cases  were 
operated  on  in  the  "interval"  {i.e.,  after 
an  acute  attack  had  subsided,  or  be- 
tween two  acute  attacks  in  chronic 
cases).    All  of  these  recovered. 

Out  of  180  cases  treated  medically,  31 


died,  giving  a  mortality  of  only  17  per 
cent.,  as  against  21  per  cent,  in  the  acute 
cases  operated  on  by  the  authors.  But 
it  must  be  observed  that  some  of  the  31 
cases  might  have  recovered  by  operation; 
on  the  other  hand,  it  may  be  argued 
that,  of  the  63  fatal  cases  operated  on, 
some  might  have  recovered  under  med- 
ical treatment  only.  If  all  cases  were 
seen  by  the  surgeon  on  the  first  or  sec- 
ond day,  every  fatal  case  would  be  oper- 
ated on  at  a  time  most  favorable  for 
cure. 

Seven  per  cent,  of  all  cases  treated  by 
other  than  surgical  means  when  first  at- 
tacked will  die,  and  the  mortality  of  all 
cases  treated  in  this  way  which  pass  to 
a  second  attack  is  14  per  cent.  On  the 
other  hand,  chances  are  three  to  one 
against  a  recurrence.  Operation  by  ex- 
perts is  practically  without  mortality; 
but  those  who  are  inexperienced  in  ab- 
dominal surgery  take  great  risks.  Every 
case  requires  consultation.  M.  C.  McCan- 
non  (Med.  and  Surg.  Bull.,  Aug.  9,  '98). 
The  more  frequent  complications  that 
may  th-wart  all  plans  of  treatment  even 
in  the  presence  of  the  most  careful  tech- 
nique: 1.  General  septic  peritonitis.  2. 
Intestinal  obstruction,  due  to  kinking  of 
the  recently  separated  intestine  or  to 
adventitious  bands.  3.  Retroperitoneal 
abscess.  4.  FEecal  fistula.  5.  Multiple 
abscess  of  the  liver.  6.  Gangrene  of  the 
CEBCum.  7.  Phlebitis  of  the  femoral  vein. 
8.  Communication  of  the  abscess  with 
the  rectum,  vagina,  or  bladder.  9.  Ven- 
tral hernia.  10.  Fatal  haemorrhage.  11. 
Parotitis.  12.  Empyema.  13.  Pericar- 
ditis. R.  A.  Sterling  (Intercol.  Med. 
Jour,  of  Australasia,  Aug.  20,  '98) . 
Cases  of  simple  catarrhal  appendicitis 
with  adhesive  peritonitis  almost  invari- 
ably get  well. 

Cases  in  which  extraperitoneal  perfo- 
ration occurs  generally  recover,  unless 
the  abscess  opens  into  the  bladder  or 
the  pleura,  when  recovery  is  doubtful. 

Cases  in  which  invasion  of  the  general 
peritoneal  cavity  by  septic  material  has 
occurred  usually  ends  fatally. 

Surgery  has  sometimes  been  successful 
even  where  there  has  been   (a)   genera! 


APPENDICITIS.     MEDICAL  TREATMENT. 


475 


suppurative  peritonitis;  (6)  septic  pare- 
sis of  the  Intestines;  (e)  multiple  ab- 
scesses in  tire  peritoneal  cavity.  Price 
(Buffalo  Med.  and  Surg.  Jour.,  Dec, 
'91). 

Diffuse  peritonitis  the  cause  of  70  per 
cent,  of  the  deaths  from  appendicitis 
Haenel  (Miinchener  med.  Woch.,  Mar, 
26,  '95) . 

Eecovery  in  a  case  of  acute  gangre 
nous  appendicitis  with  general  suppu 
rative  peritonitis.  Parker  Sims  (N.  Y, 
Med.  Jour.,  May  18,  '95). 

Eecovery  in  a  case  of  profuse  septic 
peritonitis.  The  protecting  wall  of  the 
inflammatory  adhesion  was  incomplete, 
and  the  septic  process  extended  to  the 
liver  and  the  whole  right  abdominal 
cavity.  The  pelvis  was  filled  with  puru- 
lent fluid  and  faeces.  Appendix  gan- 
grenous and  left  in.  Kakeles  (N.  Y. 
Med.  Jour.,  July  6,  '95). 

Case  of  fulminating  appendicitis.  The 
patient,  a  girl  aged  25  years,  was  oper- 
ated upon  at  5  p.m.,  twenty-four  hours 
from  the  beginning  of  the  active  symp- 
toms. The  peritoneal  cavity  was  found 
to  contain  about  two  quarts  of  pus,  the 
intestines  being  coated  throughout  with 
thick  layers  of  lymph.  Although  at 
first  the  prognosis  ■^A'as  exceedingly  bad, 
the  patient  was  convalescent  at  the  time 
the  report  was  published.  McCosh  (An- 
nals of  Surg.,  Feb.,  '97). 

Gradiial  remission  of  the  active  symp- 
toms, especially  in  the  size  of  the  tumor, 
is  a  fayorable  sign.  The  contrary  is  the 
case  when  the  remission  is  sudden. 

Pain. — If  violent,  sudden,  and  persist- 
ent, it  indicates  probable  seriousness  of 
the  attack,  but  nothing  as  to  the  natural 
defenses  for  limiting  infection.  On  the 
other  hand,  absence  of  pain  is  undecisive 
between  the  gangrene  and  resolution. 

Pulse  and  Temperature. — While  a  rapid 
pulse  and  high  temperature  favor  the  de- 
structive process,  their  absence  affords 
no  assurance  of  recovery.  Referring  to 
this,  Tyson  remarks  that  too  much  stress 
cannot  be  laid  upon  the  fact  that  there 
may  be  gangrenous  appendicitis  in  the 
presence  of  normal  temperature. 

fShock. — The  presence  of  shock,  if  un- 


doubted, is  a  very  grave  symptom,  gen- 
erally indicating  perforation.  On  the 
other  hand,  the  most  deadly  attacks 
often  occur  without  it. 

Sensitiveness. — If  persistent  and  highly 
developed,  it  generally  indicates  destruc- 
tive inflammation,  but  gives  no  clue  con- 
cerning the  limitations  of  infection. 

The  Expression. — This  is  of  material 
value  before  the  development  of  grave 
conditions. 

Ferfo)-ntion. — This  can  no  more  be 
foretold  than  the  perforation  of  the  in- 
testine in  typhoid  fever  or  the  rupture 
of  an  aneurism.  Howard  Crutcher  (Can- 
ada Lancet,  May,  '98). 

Tendency  to  recurrence  is  one  of  the 
marked  features  of  appendicitis.  The 
danger  to  life  increases  with  each  suc- 
cessive attack. 

Study  of  104  cases  of  recurring  appen- 
dicitis in  which   operation  between  the 
attacks  was  performed,  without  a  death. 
Examination  of  the  appendices  removed 
showed   that   in   not   one   case   had   the 
organ  become   normal   after   the  attack. 
Every    specimen    showed    inflammatory 
conditions.     Clinical   symptoms  are   not 
certain,  and  one  cannot  positively  deter- 
mine from  them  the  stage  which  the  in- 
flammation has  reached  nor  the  variety 
to  which  it  belongs.     Hermann  Kiimmell 
(Berliner  klin.  Woch.,  Apr.  11,  '98). 
Medical  Treatment.  —  Medical  treat- 
ment is  indicated  when  the  signs  of  ab- 
scess formation  are  not  present  and  even 
then  only  during  the  incipient  stage  of 
the  disease. 

Saline  aperient,  sulphate  of  magnesia 
in  small  doses  every  two  or  three  hours, 
combined  with  copious  warm  enemata 
or  irrigation  of  the  bowels  with  Hegar's 
funnel  syringe,  the  patient  being  in  the 
knee-chest  position,  are  of  value  to  re- 
duce the  infectious  secretions  and  dis- 
charges. 

Early  employment  of  salines  is  useful 

for  the  removal  of  toxins  and  on  account 

of  the  derivative  action.     S.  C.  Gordon 

(Amer.  Jour.  Med.  Sciences,  Jan.,  '93). 

For   distension   salines   are   of   no   use 


476 


APPENDICITIS.     MEDICAL  TREATMENT. 


except  very  early;  in  appendicitis  they 
are  decidedly  injurious.  Ricliardson 
(Amer.  Jour.   Med.   Sciences,  Jan.,  '94). 

Purgatives  are  to  be  deprecated  or 
utilized  only  when  the  local  symptoms, 
the  dangers  of  perforation  and  of  gen- 
eralized peritonitis,  are  less.  Castor-oil 
in  teaspoonful  doses  enough  to  begin  on. 
Le  Gendre,  Sevestre,  Moizard,  Mathieu 
(La  Semaine  Med.,  Nov.  28,  '94). 

For  every  ease  of  appendicitis  treated, 
at  least  five  met  with  showing  symp- 
toms so  closely  resembling  those  of  in- 
flammation of  the  appendix  that  it  was 
impossible  to  say  that  appendicitis  did 
not  e.xist  until  free  purgation  had  been 
used. 

In  simple  cases  the  cautious  use  of 
enemata  to  remove  irritating  intestinal 
contents  to  be  preferred.  Later  on  they 
tend  to  break  adhesions  by  peristalsis, 
open  perforative  ulcers,  and  spread  the 
infection.  Sehell  (N.  Y.  Med.  Jour., 
Apr.  20,  '95). 

Three  cases  in  which  rectal  injections 
of  large  doses  of  glycerin  were  advan- 
tageously used.  Joubert  (Univ.  Med. 
Jour.,  June,  '95). 

The  diagnosis  of  pain  in  the  abdomen, 
accompanied  by  fever,  should  be  assisted 
by  giving  a  purgative:  in  a  number  of 
eases  this  will  lead  to  a  rapid  and  com- 
plete cure.  Mordecai  Price  (Med.  and 
Surg.  Reporter,  Jan.  2,  '97). 

Out  of  51  cases  under  personal  super- 
vision, 44  were  successfully  treated  with- 
out operation.  The  method  consists  of 
at  first  giving  cathartic  doses  of  castor- 
oil  with  olive-oil,  followed  with  hot 
water,  until  the  bowels  are  thoroughly 
emptied.  This  is  followed  by  enemas  of 
•  glycerin  and  olive-oil.  Flaxseed  poultices 
soaked  in  olive-oil  are  applied  to  the 
abdomen.  The  diet  is  restricted  to  very 
light,  easily  digested  foods.  To  prevent 
a  return  of  the  inflammatory  process, 
after  the  original  treatment  Va  ounce  of 
olive-oil  is  given,  followed  by  a  glass  of 
hot  water  before  each  meal  for  several 
weeks.  Terry  (Medical  Times;  Canada 
Lancet,  Mar.,  '98). 

When  pus  is  present,  also  when  the 
symptoms  are  severe  from  the  outset,  and 
in  relapsing  cases  without  tumefaction 
one  should  operate.     If  operation  is  not 


performed,  rest  in  bed,  quiet,  ice-bags,  hot 
turpentine  stupes,  calomel, — the  dose  fol- 
lowed in  six  hours  by  magnesium  sul- 
phate,— or  castor-oil  alone  are  indicated. 
Diet  should  be  light:  broths  with  white 
of  egg,  milk  in  small  quantities.  No 
opium.  Ninety  per  cent,  of  all  first  cases 
treated  thus  will  recover,  at  least  tempo- 
rarily. M.  C.  McCannon  (Medical  and 
Surgical  Bull.,  Aug.  9,  '98). 
Absolute  rest  is  imperative,  and  only 
liquid  food  should  be  permitted. 

For  the  pain,  hot  fomentations  or 
poultices  or  the  ice-bag  may  be  applied 
over  the  cascal  region.  If  the  ice-bag 
is  used  it  should  be  shifted  occasionally 
or  removed  at  intervals. 

It  is  bad  practice  to  apply  blisters  and 
like  remedies  over  the  region  of  the  ap- 
pendix, when  treating  the  disease,  be- 
cause, if  operative  measures  are  subse- 
quently adopted,  there  will  be  more 
probability  of  suppuration  and  slough- 
ing in  the  wound.  0.  W.  Braymer  (Jour. 
Amer.  Med.  Assoc,  Apr.  23,  '98). 

Two   cases  of  appendicitis  in  both   of 
which    undiluted    ichthyol    was    painted 
over  the  ileo-etecal  region  twice  daily  and 
ice-bags  applied.     In   the  graver  of  the 
two  ichthalbin  was  exhibited  internally 
as  well.    Both  patients,  when  discharged, 
had  no  tenderness  on  pressure  over  the 
ileo-cascal  region.    Action  of  the  ichthal- 
bin  on   the  bowels  was  very  beneficial. 
Fuchtenbusch    (Amer.   Med.-Surg.   Bull., 
Dec.  25,  '98). 
Opium  was  at  one  time  highly  rec- 
ommended, but  it  is  now  regarded  by 
most  clinicians  as  a  dangerous  remedy. 
It   masks   the   symptoms,   and   thereby 
tends    to    compromise    the    chances    of 
operative  procedures  through  delay;   it 
locks  the  intestines  and  thereby  prevents 
the  expulsion  of  infectious  discharges. 

Opium,  by  holding  the  bowels  quiet, 
allows  the  pus  to  become  incapsulated 
by  adhesions.  Kottmann  (Corres.  f. 
Sehweizer  Aerzte,  July,  '92). 

Opium  is  the  patient's  greatest  enemj'; 
it  masks  the  symptoms  and  renders 
diagnosis  exceedingly  difficult.  J.  T. 
Johnson  (Med.  News,  Nov.  28,  '96). 


APPENDICITIS.     MEDICAL  TKEATilENT. 


477 


If  opium  has  been  given,  it  will  be  ad- 
visable for  the  surgeon  to  reserve  his 
opinion,  and  if  on  withholding  the  seda- 
tive for  a  few  hours  the  pulse  has  in- 
creased in  frequency,  and  anxiety  of  I 
countenance  has  declared  itself,  opera- 
tion will  be  required.  Mayo  Eobaon 
(Brit.  Med.  Jour.,  Dec.  19,  '96). 

Opium  paralyzes  the  nervous  tone  and 
resistance  to  microbic  proliferation,  and 
masks  symptoms.  It  is  doubtful  whether 
it  has  ever  checked  peritonitis.  Old- 
fashioned  laudanum  poultice  is  sufficient 
in  parietal  cases.  Surgical  measures  are 
required  only  in  one-third  of  the  cases 
and  should  always  be  preceded  by  med- 
ical treatment.  Talamon  (M§d.  Mod., 
No.  31,  '97). 

Proper  expectant  treatment:  Put  the 
patient  to  bed  and  keep  him  there.  Ap- 
ply over  the  whole  iliac  region  a  soap 
"poultice,"  consisting  of  a  thick  layer 
of  green  soap,  spread  on  a  single  layer  of 
muslin  or  lint.  Over  this  apply  an  ice- 
bag  or  ice-coil.  Relieve  bowels  by  soap- 
and-water  enema.  Keep  the  stomach  at 
rest  while  vomiting  exists.  Restrict  the 
patient  to  milk  or  clear  broths.  Note 
the  temperature,  pulse,  and  respirations 
every  four  hours.  Give  no  drugs.  Never 
give  opium  or  morphine  in  cases  of  ap- 
pendicitis, except  in  cases  of  abdominal 
shock  from  rupture  of  appendix  or  ab- 
scess. Syms  (N.  Y.  Med.  Jour.,  May  15, 
'97). 

Fifteen  cases  of  appendicitis  in  private 
practice,  all  of  whom  have  recovered 
without  operation.  Patients  were  all  put 
to  bed  and  kept  quiet.  All  food  was 
withheld  for  twenty-four  or  forty-eight 
hours — even  water  was  given  sparingly. 
A  saturated  solution  of  Epsom  salt  in 
peppermint-water  was  given  in  teaspoon- 
ful  doses,  one  in  three  hours,  until  one 
or  two  movements  of  the  bowels  were 
obtained  in  twenty-four  hours.  When 
stomach  was  too  irritable  to  retain  the 
Epsom  salts,  calomel  was  given  in  di- 
vided doses  until  there  were  one  or  two 
movements  of  the  bowels.  No  opiates 
were  employed.  When  patient  began  to 
eat,  food  was  given  cautiously:  a  tea- 
spoonful  of  milk  and  lime-water,  or  small 
quantity    of   beef-juice   or   some   animal 


broth,  once  in  two  or  three  hours.  Tur- 
pentine stupes  and  the  hot-water  bags 
are  of  use  in  overcoming  pain.  Opiates 
are  to  be  avoided.  Many  cases,  how- 
ever, are  surgical  from  the  beginning. 
The  result  of  medical  treatment  is  doubt- 
ful, if  within  the  first  twenty-four  hours 
after  the  patient  is  seen,  or  after  the 
bowels  have  been  sufficiently  moved, 
there  has  not  been  a  decided  improve- 
ment in  pain,  vomiting,  and  fever.  H. 
B.  Allyn   (Ther.  Gaz.,  Jan.  15,  '99). 

The  treatment  in  the  early  stages  of 
appendicitis  should  be  as  follows:  1. 
copious  warm  soap  and  water  enemata 
should  be  given,  with  the  object  of  evacu- 
ating the  lower  bowel.  2.  The  hourly 
administration,  until  the  bowels  move 
freely,  of  small  teaspoonfuls  of  sulphate 
of  magnesia  dissolved  in  about  2  wine- 
glassfuls  of  warm  water.  It  usually 
takes  from  six  to  eight  doses  before  the 
bowels  commence  to  move.  3.  Hot  lin- 
seed poultices  should  be  applied  to  the 
right  iliac  region  for  the  relief  of  pain. 
Opium  should  be  avoided  on  account  of 
its  tendency  to  mask  symptoms  and  con- 
fine the  bowels.  4.  A,Vhey,  chicken-tea, 
meat-jellies,  etc.,  may  be  given.  Milk 
only  encourages  constipation.  Ernest 
Maylard  (Glasgow  Med.  Jour.,  Mar., 
'99). 

The  prophylactic  diet  treatment  re- 
solves itself  into  the  avoidance  of  large, 
heavy  meals,  and  particularly  those 
which  are  hastily  devoured.  Milk  is  to 
be  specially  avoided,  for  it  is  a  vehicle 
for  bacteria  of  primary  importance,  and, 
further,  produces  bulky  and  scybalous 
stools.  On  the  whole,  a  liquid  and 
vegetable  diet  is  the  best  to  advise.  Sey- 
mour Taylor  (W.  London  Med.  Jour., 
Apr.,  '99). 

Nourishment  only  by  the  rectum  dur- 
ing the  acute  stage  of  appendicitis  pre- 
vents peristalsis  and  consequent  irrita- 
tion of  the  caecum  and  its  environment. 
This  method  enhances  the  patient's  op- 
portunity for  recovery.  If  vomiting  is 
present,  gastric  lavage  will  usually  quiet 
it.  A.  -J.  Ochsner  (Berliner  klin.  Woch., 
Sept.  24,  1900). 

Opium  is  sometimes  used  in  light  cases 
where  we  are  certain  that  no  affffravation 


478 


APPENDICITIS.     SURGICAL  TREATMENT. 


of  the  condition  present  it  to  take  place. 
But  this  no  one  can  foretell  with  cer- 
tainty, and  it  seems  best  to  protect  the 
patients  against  increased  chances  of 
death  by  only  employing  local  anodyne 
measures  that  will  not  mask  the  advance 
of  complications. 

A  large  number  of  catarrhal  cases  are 
cured  by  medical  treatment;  but  -when 
the  disease  advances  to  pus-formation 
surgical  treatment  is  needed.  "If  we 
err,  let  it  be  on  the  side  of  too  early, 
rather  than  on  that  of  too  long  delayed 
operation."  Da  Costa  (Med.  News,  May 
26, '94). 

The  surgeon  is  brought  face  to  face 
with  a  condition  which  has  a  recognized 
mortality  of  about  5  to  8  per  cent.:  too 
high  a  percentage.  We  first  have  to 
contend  with  the  presence  of  a  suppura- 
tion. In  450  cases  I  do  not  think  there 
has  been  an  entire  absence  of  pus  in  one 
single  instance.  I  am  satisfied  there  are 
some  cases  which  can  be  cured  by  medi- 
cine, but  can  they  be  differentiated? 
By  medical  treatment  we  have  a  mor- 
tality of  10  per  cent.,  and,  if  we  have  3 
per  cent,  by  the  knife,  then  we  must 
operate  to  save  the  other  7  per  cent. 
J.  B.  Murphy  (Amer.  Medico-Surg.  Bull., 
Oct.  10,  '96). 

In  a  series  of  517  cases  the  mortality 
was  23.8  per  cent,  in  those  of  the  cases 
treated  in  pre-operative  days.  Of  the 
517  eases,  389  were  operated  on  and  128 
treated  without  operation.  In  the  latter 
the  mortality  was  3.12.  Of  319,  81  were 
interval  cases,  in  which  there  was  1 
death.  Of  305  operated  on  in  the  acute 
stage,  68  died.  The  great  point  in  treat- 
ment is  to  anticipate  the  severer  forms 
resulting  in  septic  peritonitis  by  early 
surgical  interference.  Rule  to  advise 
operation  at  the  end  of  twenty-four 
hours  or  thirty-six  hours,  if  the  patient 
is  not  improving.  G.  E.  Armstrong 
(Lancet,  Sept.  18, '97). 
"  When  a  ease  of  diseased  appendix  is 
personally  seen  operation  is  advised;  it 
this  is  not  assented  to,  all  responsibility 
in  the  case  is  disavowed. 

Early  operation  is  admitted  by  all  to 
be    the    proper    course    in    the    acute 


perforating  peritonitis  cases.  In  ab- 
scess eases  it  means  small  abscess  easily 
and  safely  dealt  with.  In  non-perforat- 
ing cases  it  means  avoiding  all  sorts  of 
calastrophies  to  the  patient,  such  as 
perforation,  gangrene  of  the  organ 
reaching  the  surface  and  infecting  the 
peritoneal  cavity,  recurrence  of  the  dis- 
ease at  a  possible  inopportune  time, 
and  last,  but  not  least,  cure  of  his  dis- 
ease. J.  C.  Davie  (Dominion  Med. 
Monthly,  Nov.,   1901). 

Surgical  Treatment. — Operation  is  in- 
dicated:— 

1.  When  severe  symptoms  come  on 
suddenly,  either  at  the  onset  or  during 
the  course  of  the  disease. 

2.  When  in  a  mild  case  the  symptoms 
are  gradually  increasing  in  intensity  up 
to  the  third  day. 

3.  When,  by  the  third  day,  a  firm, 
gradually  growing  mass  can  be  felt  at 
the  seat  of  localized  pain,  and  especially 
if  there  is  localized  oedema. 

4.  When  abdominal  distension,  high 
pulse,  diffusion  of  pain,  and  other  evi- 
dences of  general  peritonitis  come  on  at 
any  time  in  the  course  of  the  disease. 

By  the  second  day,  certainly  by  the 
third  and  a  fortiori  later,  the  operation 
should  be  done  if  the  following  indica- 
tions are  present:  (1)  if  there  is  ab- 
dominal pain,  most  marked  in  the  right 
iliac  fossa,  and  especially  with  tender- 
ness at  McBurney's  point,  attended  pos- 
sibly with  nausea  and  vomiting;  (2)  if 
there  is  rigidity  of  the  right  abdominal 
wall;  (3)  if  there  is  fever  up  to  100°  F., 
101°  F.,  or  102°  F.,  which  does  not  yield 
to  medical  treatment;  (4)  if  by  minute 
and  careful  palpation  tumefaction  and 
increased  resistance  can  be  discovered 
with  possible  dullness  and,  rarely,  fluctu- 
ation; and  (5)  if  there  is  (Edema  of  the 
abdominal  wall.  W.  W.  Keen  (Annals 
of  Surgery,  Apr.,  '91). 

Experience  of  one  hundred  and  eighty- 
one  cases.  Operation  is  called  for  imme- 
diately in  a  sudden  severe  attack  of  ap- 
pendicitis with  pain,  vomiting,  more  or 
less    distension,    and    high    pulse,    with 


APPENDICITIS.     SURGICAL  TEEATMENT. 


479 


localized  tenderness.  In  such  a  case  the 
appendix  is  usually  perforated  and  the 
bacteria  are  very  virulent.  Kichardson 
(Amer.  Jour.  Med.   Sciences,  Jan.,  '94). 

In  entire  personal  experience  not  a 
death  seen  which  could  not  properly  he 
ascribed  to  delay  in  timely  and  skillful 
surgical  interference.  Every  case  from 
the  very  beginning  should  be  treated  by 
a  surgeon,  with  a  medical  attendant. 
Wyeth  (N.  Y.  Med.  Jour.,  June  30,  '94). 

That  some  patients  get  comparatively 
well  without  operation  no  one  denies, 
but  usually  improvement  commences  in 
such  cases  Avithin  from  twelve  to  six- 
teen hours  from  the  onset.  On  the  con- 
trary, if  the  symptoms  become  aggra- 
vated after  this  time  or  if  the  disease 
persists  in  spite  of  palliative  measures 
(opium  excluded),  it  becomes  an  opera- 
tive case,  and  the  physician  or  surgeon 
who  hesitates  to  advise  operation  robs 
his  patient  of  one  of  the  best  means 
known  to  science  at  the  present  day  of 
saving  life  in  this  dreaded  disease.  J.  C. 
Kennedy  (Med.  Eecord,  Nov.  14,  '96). 

Estimate  of  the  number  of  appendiceal 
patients  who  die  under  medical  treat- 
ment, based  on  100  consecutive  personal 
operative  eases.  In  that  particular  series 
the  death  would  have  been  about  28  per 
cent,  eventually. 

Estim.ited 
One  Hundred  Cousecntive  Operative  Under 

Appendice.ll  Cases.  Medical 

Treatment. 

7  cases  of  tuberculosis  and  can- 

cer           5 

1  case  of  strangulation  of  bowels 

by  appendix  adhesion  band.       1 
38  abscess  cases 15 

8  cases   with   hard,   incarcerated 

concretions  2 

12    cases    of    occluding    stricture 

dams    5 

34  cases  in  common  interval  stages 
or  in  acute  stages  before  ad- 
vent of  pus 0 

The  surgical  death-rate  in  this  series 

of  100  cases  was  2  per  cent.    R.  T.  Morris 

(Med.  Record,  Dec.  26,  '96). 

1.  A  frequent  or  progressively  accel- 
erated pulse-rate  of  itself  a  prime  indi- 
cation for  operation.  2.  Pain  localized 
and  progressive  is  a  valuable  associated 


condition.  When  pain  is  sudden,  severe, 
and  progressive,  and  accompanied  with 
chill,  it  means  perforation  or  abscess, 
rupture,  and  operation.  3.  Increase  of 
temperature  is  third  in  importance,  but 
when  associated  with  one  or  more  of  the 
previous  symptoms,  and  more  especially 
with  increase  of  pulse-rate,  it  makes 
immediate  operation  a  foregone  conclu- 
sion. 4.  The  gradual  subsidence  of  the 
three  cardinal  symptoms  —  pulse-rate, 
pain,  and  temperature — is  a  legitimate 
reason  for  postponing  immediate  opera- 
tive interference.  5.  In  cases  of  abscess 
it  is  generally  safer,  while  watching  for 
urgent  indications,  to  wait  until  adhe- 
sions have  formed  a  sufficiently  pro- 
tective wall.  6.  In  cases  of  recovery 
after  mild  attacks  and  without  opera- 
tion we  are  never  sure  of  recurrence 
until  the  latter  takes  place,  when  the 
operation  can  be  done  soon  enough,  and, 
all  other  circumstances  being  equal,  pref- 
erably in  the  interval  of  a  succeeding 
attack,  when  the  tissues  are  not  in  an 
inflamed  condition.  G.  F.  Shrady  (Med. 
Eecord,  Jan.  9,  '97). 

In  appendicitis  complicating  pregnancy 
early  operation  on  all  but  the  very 
mildest  cases  recommended.  1.  Within 
twelve  hours  in  acute  perforative  cases. 
2.  A  rapid  pulse  (116  to  120)  is  a  strong 
indication  for  operation.  3.  If  doubt 
exists,  operation.  4.  If,  after  a  sudden 
lull  in  symptoms,  recurrence  manifests 
itself,  operation.  5.  In  recurrent  at- 
tacks, during  pregnancy,  even  if  mild, 
operation  indicated,  especially  in  the 
early  months  of  gestation.  This  re- 
moves the  possibility  of  a  future  attack 
in  the  later  months,  when  the  procedure 
is  more  difficult.  Abrahams  (Amer. 
Jour.  Obst.,  Feb.,  '97). 

Views  of  a  large  number  of  represen- 
tative surgeons  on  chief  indications  for 
operation:  1.  Operation  during  the  first 
twenty-four  hours  gives  a  mortality  of 
1  to  2  per  cent.,  but  60  per  cent,  of  these 
operations  are  unnecessary.  2.  Opera- 
tion only  in  very  severe  cases  and  for 
suppuration  gives  a  mortality  of  17  to 
25  per  cent.  3.  Operation  between  these 
extremes  gives  a  mortality  of  14  per 
cent.  Frederick  Winnett  (Canadian 
Practitioner,  Mar.,  '97). 


480 


APPENDICITIS.     SUEGICAL  TREATMENT. 


As  soon  as  appendicitis  is  diagnosed, 
no  matter  how  mild  the  case  may  be, 
an  immediate  operation  should  be  per- 
formed, unless  a  patient  is  in  severe 
shock  following  sudden  perforation.  In 
such  cases  the  shock  should  be  first  over- 
come. 

Series  of  81  cases,  all  acute  with  1  ex- 
ception, all  suppurative  or  gangrenous, 
and  4  complicated  with  peritonitis  in 
which  appendicectomy  was  performed 
with  perfect  recovery  with  1  exception. 
Operation  favored  in  the  acute  stage  and 
as  soon  as  diagnosis  is  made.  Twice  the 
appendix  was  found  on  the  left  side  of 
the  body;  the  cases  were  consecutive 
suppurative  or  gangrenous  appendicitis. 
In  all  but  1  the  appendix  was  perforated. 
Bernays  (Med.  Record,  Apr.  2,  '98). 

Two  cases  of  appendicitis  in  pregnant 
women  operated  on.  Both  cases  re- 
covered and  neither  miscarried.  One 
sliould  not  hesitate  to  operate  during 
any  period  of  pregnancy,  or  even  during 
parturition,  if  the  case  requires  it.  Hun- 
ter McGuire  (Southern  Med.  Record; 
Canada  Lancet,  May,  '98). 

Case  of  successful  operation  for  ap- 
pendicitis during  the  eighth  month  of 
pregnancy;  dermoid  cyst  with  a  twisted 
pedicle  also  removed.  Twelve  hours  after 
the  operation  labor-pains  set  in  and  the 
woman  was  normally  delivered  of  a  live 
child.  At  time  of  report,  just  fourteen 
days  after  the  operation,  botli  mother 
and  child  are  alive  and  well.  A.  G.  Ger- 
ster  (Annals  of  Surg.,  May,  '98). 

Operation  advocated  at  the  earliest 
possible  opportunity  in  all  those  cases 
which  have  not  shown  definite  signs  of 
improvement  within  thirty-six  hours. 
Suppuration  occurs  in  a  very  much 
larger  proportion  of  cases  of  inflamed  ap- 
pendix than  is  usually  believed.  In 
many  of  these  the  abscess  bursts  sud- 
denly into  the  bowel  with  instantaneous 
remission  of  all  the  symptoms;  in  others 
the  pus  gradually  becomes  inspissated 
and  dried  up.  It  is  true  that  many  of 
these  cases  recover  without  operation, 
but  it  is  not  good  surgery  to  leave  an 
abscess  in  close  proximity  to  the  general 
peritoneal  cavity  in  the  hope  that  it  will 
not  burst  into  it. 

Another   argument   in   favor   of   early 


operation  is  the  very  grave  effect  upon 
mortality  which  the  postponement  of  the 
operation  exerts  in  the  case  of  those  who, 
because  of  suppuration  or  of  diffuse  peri- 
tonitis, come  to  operation  at  last.  Fow- 
ler, analyzing  127  cases,  showed  that  83 
per  cent,  recovered  of  those  patients  who 
were  operated  upon  in  the  first  three 
days;  60  per  cent,  of  those  operated 
upon  on  the  fourth  day;  58  per  cent,  of 
those  operated  upon  on  the  fifth  and  sixth 
days;  50  per  cent,  of  those  operated  upon 
on  the  seventh  and  eighth  days;  and 
only  33  per  cent,  of  those  operated  upon 
on  the  ninth  and  tenth  days.  As 
Murphy  has  phrased  it,  one-half  of  all 
the  patients  who  would  have  recovered 
by  operation  will  die  if  we  wait  until  the 
sixth  day. 

If  in  a  case  of  inflamed  appendix 
thirty-six  hours  have  passed  without 
definite  improvement  having  shown  itself, 
the  responsibility  for  the  consequences 
must,  it  seems,  rest  with  those  who 
recommend  that  an  operation  should  not 
be  performed.  C.  Mansell  MouUin  (Lan- 
cet, Dec.  16,  '99). 

At  first,  after  a  mild  attack,  resort 
may  be  had  to  the  regulation  of  the 
diet  and  to  salines.  Should  the  attack 
be  repeated,  or  should  the  first  attack 
be  a  severe  one,  the  appendix  should  be 
removed.  Opium  or  morphine  should  not 
be  given  during  an  attack;  neither 
should  an  operation  be  performed  during 
an  attack  unless  (1)  a  chill  should 
manifest  itself;  (2)  the  pain  should  be 
severe  enough  to  require  morphine;  (3) 
the  pulse  is  small,  rapid,  or  irregular; 
(4)  there  is  persistent  vomiting;  (5) 
there  is  persistent  rigidity  of  the  abdom- 
inal wall;  (6)  an  abscess  can  be  felt; 
(7)  the  general  condition  makes  it  im- 
perative; (8)  in  doubt.  Joseph  Wiener, 
Jr.   (Med.  Record,  May  19,  1900). 

Operation  advised  within  the  first 
twenty-four  hours,  since  during  that 
time  it  can  be  done  with  a  maximum 
mortality  of  2  per  cent.  The  diagnosis 
can  very  readily  be  made  within  the  first 
twenty-four  hours.  If  the  case  is  past 
the  first  seventy-two  hours  when  first 
seen,  it  may  sometimes  be  allowed  to 
proceed  without  operation,  if  there  is  a 
circumscribed  abscess  with  low  tempera- 


APPENDICITIS.    SURGICAL  TREATMENT. 


481 


ture  and  no  indication  of  great  intoxica- 
tion. J.  B.  Murphy  (Chicago  Med. 
Record,  June,  1900). 

Delay  in  operation  is  a  common  cause 
of  fistula.  There  are  two  types,  the  ex- 
ternal and  internal,  the  former  being 
divided  into  the  simple  and  fiEcal.  The 
simple  form  of  fistula  is  an  external 
channel  leading  to  an  unhealed  abscess, 
and  corresponds  to  the  di'ainage  tract. 
This  tends  to  heal  spontaneously,  and  it 
is  often  due  to  some  foreign  body  in 
the  tract.  A  second  variety  of  the  simple 
fistula  is  where  the  lumen  of  the  appen- 
dix is  in  direct  communication  with  the 
tract.  In  these  cases  clear  mucus  is  dis- 
charged, and  the  absence  of  faecal  matter 
is  due  to  the  fact  that  the  inflammatory 
process  has  separated  the  caecum  from 
the  appendix.  J.  B.  Deaver  (Jour.  Amer. 
Med.  Assoc,  July  14,  1900). 

Report  based  on  the  results  of  personal 
experience  in  40  cases  of  acute  appendi- 
citis seen  during  the  past  year.  In  gen- 
eral peritonitis  several  cases  recovered 
in  spite  of  extensive  involvement  of  the 
peritoneum  in  the  inflammatory  process: 
a  feature  attributed  to  abundant  saline 
irrigation  of  the  peritoneal  cavity 
through  a  moderate  incision  without 
evisceration  when  wide-spread  purulent 
peritonitis  was  present.  There  were  8 
of  these^  3  of  which  were  fatal.  Several 
of  the  patients  who  recovered  not  only 
presented  the  signs  of  severe  sepsis,  but 
the  appearance  of  the  interior  of  the 
abdomen  was  in  several  instances  exceed- 
ingly unfavorable.  Had  the  intestines 
been  removed  from  the  cavity  and 
washed  and  wiped,  the  patients  would 
not  have  recovered.  This  method  of 
treatment  in  cases  of  purulent  peritonitis 
condemned.  The  immediate  effect  is  a 
severe  strain  upon  the  lowered  vitality 
of  the  parts  and  subsequent  paresis  of 
the  bowel  is  frequent.  A.  B.  Johnson 
(Med.  Record,  Nov.  3,  1900). 

A  large  number  of  athletes  require  the 
removal  of  the  appendix.  If  we  made  it 
a  practice  to  operate  when  the  trouble 
is  first  recognized,  without  the  delay  of 
a  day  or  more  for  consultations  and 
for  therapeutical  treatment,  the  deaths 
would  be  very  few.  The  so-called  very 
"conservative"   man   gives    us    tlie    ugly 

i— ; 


abscess  class  of  cases,  and  the  virulent, 
perforative  cases.  Joseph  Price  (.Jour. 
Amer.  Med.  Assoc,  Nov.  24,   1900). 

The  ideal  time  to  operate  in  appendi- 
citis to  obtain  ideal  results  is  in  the 
stage  of  appendicular  colic,  before  in- 
flammation has  taken  possession  of  the 
vulnerable  tissues  composing  this  organ. 

Formerly  abscess-formation  was  re- 
garded as  the  indication  for  operation, 
certainly  a  most  unfortunate  view,  for 
tlien  the  time  for  an  ideal  operation  has 
passed. 

An  abscess-cavity  must  heal  by 
granvilation,  cicatrization,  and  contrac- 
tion. In  appendicular  abscess  of  any 
size  the  inner  wall  is  formed  by  ail- 
herent  loops  of  small  bowel.  During 
contraction  the  calibre  of  the  bowel  is 
often  occluded,  and  acute  mechanical 
obstruction  results,  which,  unless  re- 
lieved by  immediate  operation,  must  re- 
sult in  the  death  of  the  patient. 

In  personal  experience  at  the  German 
Hospital,  where  yearly  from  one  hun- 
dred and  fifty  to  two  hundred  opera- 
tions are  performed  for  acute  appendi- 
citis, many  of  which  are  of  the  abscess 
type,  the  percentage  of  intestinal  ob- 
struction is  comparatively  small.  Tliis 
condition,  which  usually  does  not  occur 
for  ten  days,  is  so  feared  that,  upon 
the  appearance  of  paroxysmal  abdom- 
inal pain,  nausea,  inability  to  pass  flatus 
or  to  have  the  bowels  moved  by  simple 
purgative  medicines  aided  by  high 
enemata  through  the  rectal  tube  and 
given  by  hydrostatic  pressure,  and  with 
the  presence  of  slight  tympany  with 
paroxysmal  pains  provoked  by  gentle 
palpation  of  the  abdominal  wall,  a  sec- 
tion is  immediately  advised.  By  this 
practice  recoveries  are  recorded  in  pa- 
tients that  otherwise  would  have  per- 
ished. 

It  is  personal  practice  in  dealing  with 
these  large  abscess  cases  not  to  be  eon- 
tent  with  the  evacuation  of  the  abscess 
and  the  removal  of  the  appendix,  but, 
further,  to  relieve  the  adherent  coils 
of  bowel,  which,  done  with  proper  ma- 
nipulation, skill,  and  disposition  of 
sterile  gauze  to  guard  against  infection 
of  the  general  peritoneal  cavity,  and 
the  placing  of  gauze  drains,  prevents  this 


482 


APPENDICITIS.     OPERATIVE  TECHNIQUE. 


complication  being  more  common  tlian  it 
otherwise  would.  Again,  in  these  ab- 
scess cases  it  happens  frequently  that, 
in  addition  to  the  principal  focus  of 
suppuration,  there  are  other  foci.  In 
sucli  instances  the  evacuation  of  the 
primary  focus  of  pus  does  not  neces- 
sarily mean  the  evacuation  of  the  sec- 
ondary collections.  This  phase  of  treat- 
ment is  one  of  the  most  important; 
overlooking  secondary  collections  figures 
conspiouotisly  in  the  mortality  of  this 
class  of  cases. 

Where  the  appendicular  inflammation 
has  involved  to  any  degree  the  neighbor- 
ing structures,  particularly  the  great 
omentum,  as  is  so  commonly  seen  in 
abscess  cases,  it  is  necessary  to  tie  oS 
the  involved  portion  of  the  omentum, 
which  frequently  is  partly  or  entirely 
gangrenous.  The  sooner  the  appendix 
is  out,  the  better  for  the  subsequent 
welfare  of  the  patient.  J.  B.  Deaver 
(New  York  Med.  Jour.,  Deo.  7,  1901). 

The  conservative  treatment  of  ap- 
pendicitis consists  in  prompt  operation. 
The  starvation  method  of  procrastina- 
tion is  vicious  and  has  cost  many  lives, 
because  it  is  used  as  an  excuse  to  dally 
with  patients  that  should  be  promptly 
subjected  to  removal  of  the  organ.  J. 
H.  Carstens  (New  York  Med.  Jour., 
Jan.  18,  1902). 

Aspiration  of  the  abscess  tlirough  the 
abdominal  wall  is  only  indicated  when 
it  is  clearly  superficial;  otherwise  the 
chances  of  striking  the  abscess  itself  are 
very  small  and  the  risk  may  be  great. 
Large  abscesses  may  sometimes  be  evacu- 
ated through  the  rectum. 

There  are  cases  in  which,  although 
the  diagnosis  is  not  absolutely  certain, 
it  may  be  quite  justifiable  to  make  an 
exploratory  incision.  MacCormac  (Clin- 
ical Jour.,  Sept.  26,  '94). 

It  is  preferable  to  perform  an  aseptic 
exploratory  section  and  be  proved  wrong 
in  diagnosis  than  to  wait  until  an  opera- 
tion is  rendered  necessary  by  perforation 
and  peritonitis.  Grandin  (N.  Y.  Med. 
Record,  Dec.  1,  '94). 

Enormous  appendiceal  abscess  incised 
through   the  rectum.     Operation  not  al- 


lowed by  the  patient,  and  the  abscess 
gradually  increased  in  size  for  about  two 
weeks,  his  pulse  being  then  100  and  tem- 
perature 99.5°  F.  The  abdomen  was 
quite  filled  with  a  fluctuating  tumor 
reaching  within  one  and  one-half  inches 
of  the  umbilicus,  filling  up  the  right 
side.  It  extended  almost  to  the  iliac 
crest  on  the  left  side,  simulating  an  enor- 
mously distended  bladder,  except  that 
the  area  of  flatness  was  greater  toward 
the  flanks.  A  rectal  examination  showed 
that  the  pus  had  burrowed  into  the  pel- 
vis so  as  to  dilate  the  anal  sphincter. 
An  opening  was  made  through  the  rec- 
tum, and  when  the  sac  was  incised  the 
tension  was  so  great  that  the  pus  was 
thrown  out  for  a  considerable  distance. 
Over  a  gallon  of  foetid  pus  was  dis- 
charged. Rapid  recovery  followed. 
Reuben  Peterson  (Milwaukee  Med.  Jour., 
Apr.,  1900). 

Operative  Technique. — Incision. — 
The  incision  that  is  generally  preferred 
at  present  is  that  recommended  by  Mc- 
Burney  (see  &,  colored  plate).  It  crosses 
an  imaginary  line  (a)  drawn  from  the 
anterior  superior  spine  of  the  ilium  (Z?) 
to  the  umbilicus  [A)  at  the  juncture  of 
its  middle  and  lower  thirds,  and  thus 
overlying  the  diseased  structures.  The 
integument  and  aponeurotic  structures 
are  alone  to  be  incised,  the  muscular 
fibres  being  separated  by  means  of  the 
scalpel-handle  in  a  line  parallel  to  their 
course.  As  a  result,  muscular  action  will 
rather  tend  to  approximate  than  to  draw 
apart  the  edges  of  the  wound  and  thus 
prevent  post-operative  hernia:  a  condi- 
tion frequently  met  with,  especially  when 
the  median  incision  was  generally  used. 
The  latter  is  still  resorted  to  by  some 
surgeons,  and  is  especially  useful  when 
diffuse  abscess  is  present. 

The  lateral  incision  is  preferred,  be- 
cause (1)  it  lies  directly  over  the  route 
of  the  appendix;  (2)  it  exposes  the  fleld 
of  operation  more  favorably  than  the 
median;  (3)  it  creates  a  shorter,  a  less 
exposed,  line   of  drainage.     The   advan- 


APPKNJJlCiTIS.     OPERATIVE  TECHNIQUE. 


483 


tages   of   the   median   incision   are:     (1) 
greater  probability  of  not  encountering 
adhesions  between  the  anterior  wall  and 
tlie  intestines  in  the  line  of  incision;   (2) 
easier  access  to  all  parts  of  the  peritoneal 
cavity    for    washing    and    for    drainage. 
Joseph   Price    (Buffalo   Med.    and   Surg. 
Jour.,  Dec,  '91). 
The  frequency  of  post-operative  her- 
nia has  caused  surgeons  to  greatly  reduce 
tlie  length  of  incisions,  and  Morris  has 
shown  that  an  opening  through  the  mus- 
cular tissues  1  Va  inches  in  length  was 
sufficient  in  the  majority  of  instances. 
McBurney  has  found  that  even  in  his 
method  the  opening  in  the  deeper  layers 
of  the  abdominal  wall  need  not  be  more 
than  two  inches  in  length. 

Probably  few  appreciate  the  number 
of  cases  of  hernia  following  this  opera- 
tion. Since  April,  1895,  there  have  been 
observed  at  the  Hospital  for  the  Rupt- 
ured and  Crippled  fifty-five  cases.  There 
was  evidence  that  in  many  instances 
the  wound  was  improperly  closed.  Per- 
haps in  a  large  majority  of  the  cases 
there  had  evidently  been  suppuration 
during  the  healing  of  the  wound.  Coley 
(Annals  of  Surg.,  Aug.,  '97). 

Surgeons  are  now  using  a  much 
smaller  incision  than  formerly  in  order 
that  they  may  avoid  post-operative 
hernia,  which  is  due  to  the  fact  that 
the  lines  of  muscle-traction  at  this  point 
are  different  in  the  different  muscles. 
A  pad  over  the  seat  of  operation  induces 
hernia  by  causing  absorption  of  the 
new  connective  tissue  as  it  is  being 
formed.  The  margin  of  each  muscle 
should  be  separated  with  the  greatest 
care  when  operating;  likewise  care 
should  be  taken  in  dividing  the  peri- 
toneum. In  closing  the  wound  each 
diflferent  layer  of  muscular  tissue  as 
well  as  the  peritoneum  and  fascia  should 
be  united  with  the  same  tissue  from 
which  it  was  separated  in  the  beginning. 
Thus  the  lines  of  muscular  traction  will 
not  be  disturbed,  and  hernia  is  less  likely 
to  be  produced.  No  bandage  or  pad 
should  be  applied.  The  patient  should 
be  kept  in  bed  for  at  least  twenty-five 
days    following    the    operation.      P.    T. 


Morris      (Southern     Practitioner,     Nov., 
'97). 

McBurney  recommended  his  method 
only  for  non-suppurative  cases  or  those 
in  which  drainage  was  not  required,  but 
many  surgeons  employ  it  with  advan- 
tage in  almost  all  cases  of  appendicitis, 
including  those  in  which  an  abscess  is 
present  and  where  drainage  is  required. 
Three   illustrative   cases.     In   all,    the 
abdomen   had  been  opened  by  splitting 
the  aponeurosis  of  the  external  oblique, 
separating  the  fibres  of  the  underlying 
muscles,    and    dividing    the    fascia    and 
peritoneum   transverselj'.     After   having 
removed  the  appendix  and  the  pus,  and 
inserted   gauze    and   rubber   drains,    the 
opening    was    narrowed    by    catgut    su- 
tures in  the   different  layers,  leaving  a 
hole  not  more  than  an  inch  in  diameter, 
which   proved   ample   for   drainage.     In 
cases  in  which  the  opening  proved  too 
small  to  permit  of  the  necessary  manipu- 
lation within  the  abdomen,  it  could  be 
enlarged  by   cutting  at  right  angles  to 
the  deeper  part  of  the  incision  along  the 
border    of    the    rectus;     this    secondary 
incision  could  then  be  closed  by  suture, 
and    drainage    made    through    the    pri- 
mary portion  as  in  other  cases.    Stimson 
(Annals  of  Surg.,  Mar.,  '97). 

The  McBurney  method  employed  dur- 
ing the  past  year  in  all  suppurative  as- 
well  as  non-suppurative  cases.  Without 
cutting  muscular  structures  it  is  possible 
to  separate  the  internal  oblique  and 
transversalis  muscle  fibres  in  an  out- 
ward direction,  so  as  to  make  a  large 
enough  opening  to  approach  any  abscess- 
cavity  in  the  iliac  fossa  and  perform 
necessary  manipulation  in  suppurative 
cases,  including  ligation  or  treating  the 
appendix  as  desired.  In  leaving  an 
opening  in  the  intermuscular  space  to 
permit  drainage  there  was  no  trouble  in 
subsequent  healing  of  the  wound.  The 
natural  tendency  of  the  muscular  fibres 
to  draw  together  in  the  direction  of  their 
length  approximated  those  which  had 
been  drawn  out  of  their  course,  and  per- 
mitted them  to  resume  their  function. 
As  a  rule,  after  granulation  the  wound 
unites    in    a    fine,    linear   scar,    without 


484 


APPENDICITIS.     OPERATIVE  TECHNIQUE. 


stitching.     Abbe  (Annals  of  Surg.,  Aug., 
'97). 

For  the  prevention  of  ventral   hernia 
McBurney's      muscle-splitting      incision 
reeommended,  even  though  pus  be  pres- 
ent;   most  of  the  wound  is  sutured  and 
provisional  sutures  are  placed  which  can 
be    tied    later.      The    early    removal    of 
drainage  is  a  matter  of  great  importance, 
the  gauze  drain  is  replaced  by  a  shorter 
drain    or   by    a    drain    of   rubber   tissue 
folded  on  itself  like  a  fan.    The  removal 
of  the  appendix  is  advised  when  possible. 
The  patients  are  kept  in  bed  three  weeks, 
and  at  the  end  of  this  time  firm  union 
is  usually  obtained.     G.  Woolsey   (Med. 
Record,  Apr.  1,  '99). 
Some  operators  have  found  that  when 
the  appendix  is  in  the  normal  position 
and  is  not  difScult  to  bring  out,  Mc- 
Burney's method  is  almost  ideal;    but 
when  difficulties  arise  and  the  incision 
has  to  be  enlarged,  the  necessarily  con- 
stant and  hard  retraction  of  the  muscles 
is  likely  to  injure  the  tissue  and  some- 
times to  cause  suppuration.    If  it  is  nec- 
essary to  enlarge  the  wound,  there  results 
a  ragged  and  complicated  wound,   not 
well  adapted  to  drainage  if  pus  is  found. 
The  position  of  McBurney's  incision  is 
also  thought  by  some  to  render  proper 
■drainage  difficult  to  obtain.     Other  in- 
cisions are  therefore  resorted  to. 

The  hypogastric  incision  (/)  may  be 
more  or  less  near  the  spine  of  the  ilium, 
beginning  a  little  above  the  line  drawn 
from  the  umbilicus  to  the  spine  of  the 
ilium,  or  it  may  be  made  wholly  below 
this  line.    At  the  outset  it  may  be  two 
inches  in  length,  and  subsequently  be 
extended  in  either  direction  if  necessary. 
This    incision    affords    the    following 
advantages:    Less  danger  of  injuring  the 
subjacent  intestine,  the   ileum,   and  the 
caput  coli;    less  tendency  to  prolapse  of 
the  omentum  and  the  ileum;    it  "walls 
off"  the  general  peritoneal   cavity  with 
facility    and    certainty;     it    affords    ex- 
cellent drainage  at  the  time  of  the  oper- 
ation, as  well  as  subsequently.     An  ab- 


scess can  be  opened  on  its  outer  aspect 
in  such   a  way  as  to  prevent  infection 
of    the    peritoneal    cavity:     a    point    of 
much  importance.    A  minimum  of  injury 
is  done  to  the  muscles  and  nerves,  and 
repair  has  not  been  followed  by  ventral 
hernia.    J.  S.  Wight  (N.  Y.  Med.  Jour., 
Oct.  24,  '96). 
An  incision  proposed  by  Jalaguier  and 
recently  recommended  by  Kammerer  is 
especially  applicable  to  cases  occurring 
in  slim  children.     It  is  thought  to  pre- 
vent post-operative  hernia  better  than 
any  other.    The  skin  and  the  aponeurosis 
of  the  external  obliqite  are  incised  at  the 
outer  border  of  the  rectus  (d),  and  the 
aponeurosis  on  the  inner  side  of  this  in- 
cision is  then  dissected  for  some  distance 
from  the  anterior  sheath  of  the  muscle, 
and  drawn  toward  the  median  line,  ex- 
posing the  sheath.    An  incision  (e)  paral- 
lel to  the  first  is  then  made  in  the  latter 
sheath  about  one-half  inch  to  the  inside 
of  the  border  of  the  rectus,  exposing  the 
muscle!    When  the  operation  is  finished, 
the  deeper  incision  is  closed   and  the 
rectus,  permitted  to  slip  in  place,  acts  as 
protecting  covering.     Kammerer  recom- 
mends it  for  adults. 

Modified  incisions  have  also  been  pro- 
posed by  other  surgeons,  among  which 
those  of  Elliott,  Vischer,  Willy  Meyer, 
Fowler,  and  Weir  may  be  mentioned. 

To  avoid  the  drawbacks  of  the  Me- 
Burney  incision  a  longitudinal  cut  is 
made  through  the  skin  and  the  apo- 
neurosis of  the  external  oblique,  begin- 
ning one-half  inch  inside  the  anterior 
spine  of  the  ilium,  and  extending  to  the 
linea  semilunaris.  The  fibres  of  the  ex- 
ternal oblique  are  thus  cut  across,  but 
the  fibres  of  the  internal  oblique  and 
transversalis  are  separated  as  in  the 
MeBurney  operation.  The  \vound  is 
closed  by  passing  two  rows  of  sutures 
through  all  the  layers  of  the  abdomen, 
to  prevent  a  dead  space,  and  uniting 
the  cut  edges  of  the  external  oblique 
with  a  continuous,  buried,  silk  suture. 
No  nerves  or  muscles  are  cut;    there  is 


APPENDICITIS.    OPERATIVE  TECHNIQUE. 


485 


no  resulting  anaesthesia  of  the  skin.  The 
aponeurosis  of  the  external  oblique  has 
united  well  in  every  case.  Elliot  (Bos- 
ton Med.  and  Surg.  Jour.,  Oct.  29,  '96). 

To  easily  locate  the  appendix  and 
facilitate  free  drainage,  an  incision  is 
made  through  a  more  muscular  and 
dependent  portion  of  the  abdominal  wall 
an  inch  above  and  parallel  to  the  crest 
of  the  ilium^  beginning  at  the  outer 
edge  of  the  external  oblique,  and  run- 
ning forward  to  a  point  corresponding 
to  the  anterior  superior  iliac  spine,  or, 
if  necessary,  slightly  beyond  this.  Hav- 
ing divided  the  skin  and  aponeurosis, 
the  external  oblique,  which  is  found  well 
developed  at  this  point,  and  its  fibres 
running  nearly  vertical,  is  separated, 
after  which  the  internal  oblique  and 
transversalis,  which  are  also  well  devel- 
oped, and  whose  fibres  run  nearly  on  one 
plane,  are  separated,  exposing  the  trans- 
versalis fascia.  This,  together  with  the 
peritoneum,  is  divided  in  a  vertical  direc- 
tion. This  will  be  found  to  have  opened 
the  peritoneal  cavity  at  its  lowermost 
plane  and  near  to  the  attachment  of  the 
caecum.  A  finger,  now  being  introduced, 
invariably  comes  in  contact  Avith  the 
caput  coli,  which  can  be  readily  drawn 
into  the  wound,  and  thereby  facilitate 
the  search  for  the  appendix.  In  sup- 
purative eases,  the  pus-cavity  being 
opened  at  this  point,  drainage  follows 
at  the  most  dependent  point.  The  great- 
est disadvantages  are  the  depth  of  the 
wound  and  haemorrhage  from  a  small 
muscular  branch  of  the  circumflex  iliac 
artery,  which  can  readily  be  controlled. 
Vischer   (Annals  of  Surg.,  Nov.,  '97). 

"Hockey-stick"  incision  in  appendicitis 
admits  of  the  fibres  of  the  oblique  and 
transversalis  being  separated  and  not  cut 
transversely;  at  the  same  time  sufficient 
room  is  obtained,  not  only  for  the  re- 
moval of  the  appendix,  but  for  meeting 
any  complications  that  may  exist  in  the 
pelvis  upon  the  right  side.  The  incision 
begins  above,  midway  between  McBur- 
ney's  point  and  the  anterior  superior 
spine  of  the  ilium.  It  descends  parallel 
with  a  line  drawn  from  the  pubis  to  the 
anterior  superior  spine,  and,  when  above 
Poupart's  ligament  on  a  line  with  the 
femoral  artery,  curves  at  an  obtuse  angle 


and  is  extended  as  far  as  the  border  of 
the  rectus  muscle.  In  making  the  hori- 
zontal part  of  the  incision  care  must 
be  taken  not  to  injure  the  epigastric 
artery.  Willy  Meyer  (Jour.  Amer.  Med. 
Assoc,  Feb.  17,  1900). 

New  method  of  opening  the  abdomen 
in  cases  of  simple  appendicitis:  The  skin 
incision  commences  at  the  upper  rounded 
prominence  of  the  anterior  superior  spine 
of  the  ilium  and  is  carried  almost  hori- 
zontally to  the  outer  edge  of  the  rectus, 
from  which  point  it  is  curved  downward 
for  about  two  and  one-half  inches.  The 
triangular  flap  is  then  dissected  down- 
ward and  outward,  exposing  aponeurosis 
of  the  external  oblique.  A  retractor 
is  applied  at  the  lower  angle  of  the 
wound  and  at  the  middle  of  the  trans- 
verse incision,  and  traction  exposes  three 
inches  of  the  aponeurosis,  which  is  di- 
vided in  the  direction  of  its  fibres.  Two 
more  retractors  are  applied  and  the 
sheath  of  the  rectus  exposed  likewise 
and  opened.  The  rectus  muscle  and  deep 
epigastric  vessels  are  retracted  median- 
A\ard,  exposing  for  four  inches  in  a 
transverse  direction  the  internal  oblique 
and  its  aponeurosis.  A  transverse  in- 
cision is  now  carried  down  through  the 
remaining  layers  into  the  abdominal 
cavity,  making  a  wound  which  by  proper 
retraction  gives  ample  room  for  an  ap- 
pendectomy. In  closing  the  wound  the 
different  layers  are  closed  by  continu- 
ous sutures  running  in  the  lines  of  in- 
cision, care  being  taken  in  suturing  the 
external  oblique  aponeurosis  that  the 
sheath  of  the  rectus  abdominalis  is  in- 
cluded. Fowler  (Med.  News,  Mar.  3, 
1900;     Phila.   Med.   Jour.). 

Method  of  operating  on  appendicitis 
by  incising  the  external  oblique  fascia 
and  then  forcibly  separating  the  muscles 
is  so  superior  to  the  older  method  of 
cutting  through  the  muscle  in  the  pre- 
vention of  hernia  that  it  is  the  operation 
par  excellence  in  many  cases.  It,  how- 
ever, does  not  provide  sufficient  room 
for  the  complicated  cases,  and  the  incis- 
ing of  the  intermuscular  space  upward 
along  the  border  of  the  rectus  has  proved 
unsatisfactory.  Proposition  to  gain  the 
necessary  room  by  tearing  the  denuded 
fascia  of  the  external  oblique  from  the 


486 


APPENDICITIS.    OPERATIVK  TECHNIQUE. 


sheath  of  the  rectus  quite  up  to  the 
median  line.  The  anterior  sheath  of  the 
rectus  is  there  divided  transversely  in  a 
line  continuous  with  the  opening  made 
in  the  peritoneum  by  the  original  muscle- 
separation  operation.  The  rectus  muscle 
can  now  be  retracted  medianward  and, 
after  ligation  or  retraction  of  the  epi- 
gastric vessels,  the  posterior  sheath  and 
peritoneum  can  be  cut  in  a  direction 
similar  to  the  anterior  sheath.  The 
procedure  allows  the  greatest  access  pos- 
sible to  the  right  iliac  fossa.  The  sheaths 
of  the  rectus  should  be  closed  with  cat- 
gut. R.  P.  Weir  (Phila.  Med.  Jour., 
from  Med.  News,  Feb.  17,  1900). 

The  abdominal  walls  having  been 
penetrated,  the  margins  of  the  wound 
are  then  retracted  by  an  assistant,  unless 
the  abscess  has  already  reached  the  sur- 
face. The  peritoneum  is  then  divided 
freely,  but  with  great  care. 

Matted  coils  are  gently  separated  and 
intestinal  prolapse  and  contact  with  dis- 
eased surfaces  are  prevented  by  carefully 
packing  the  cavity  around  the  caecum 
with  pads  of  iodoform  gauze,  the  ends 
remaining  outside  or  being  held  by 
clamps.  This  should  be  done  in  such  a 
manner  that  no  infected  tissue  or  fluid 
be  in  any  way  brought  in  contact  with 
the  healthy  peritoneum.  The  walls  of 
the  pus-cavity  are  then  disinfected  with 
a  bichloride  solution  of  1  to  5000. 

The  cfflcum  being  now  isolated,  it  is 
important  to  also  remove  the  cause  of 
the  abscess  or  its  contents  without  caus- 
ing septic  material  to  invade  the  general 
peritoneal  cavity. 

If,  in  handling,  any  adhesions  are 
broken  through,  it  is  quite  easy  for  a 
coil  of  intestine  which  is  not  infected 
to  enter  the  abscess-cavity  through  the 
opening  made  and  to  become  at  once 
infected,  then  rapidly  disappear  and 
reach  a  situation  where  it  is  entirely 
beyond  control;  or,  if  such  an  acci- 
dental break  in  the  wall  of  the  abscess 
have  been  made  and  a  small  quantity 
of    the     abscess-contents     have    escaped 


among  the  uninfected  intestines,  fatal 
infection  may  result.  McBurney  (Buf- 
falo Med.  Jour.,  June,  '96). 

But  two  incisions  personally  used  for 
appendicitis:  the  gridiron,  or  McBurney 
incision,  and  the  clean  cut  through  all 
the  tissues  from  the  skin  into  the  peri- 
toneal  cavity.     The   former    should   be 
selected  w^hen  the  conditions  justifj-  it ; 
that  is,  in  all  clean  cases,  in  those  oper- 
ated upon  in  the  period  of  quiescence 
and   in   others   when   the   inflammatory 
and  septic  processes  are  limited  either 
within   the   lumen   of   the   appendix   or 
immediately  about  its  walls  and  when 
there  is  no  more  than  a  limited  local 
peritonitis.      An    incision    shorter    than 
three    inches    except    in    eases    of   well- 
marked    abscess    is    not    advisable.      In 
this  condition  it  is  best  simply  to  incise 
and    puncture    and    drain    the    abscess. 
AVhen    a    condition    of    sepsis    prevails, 
such  as  to  require  a  careful  operation 
to    prevent    widespread    infection    and 
peritonitis,  the  writer  prefers  the  clean 
incision    through    everything    from    the 
skin  and  including  the  peritoneum.    The 
technique    of    both    methods    is    given 
briefly.     When   the   "gridiron"   incision 
is  used  it  maj'  not  be  necessary  to  keep 
the    patient    in    bed    as    long    as    when 
"tlirough-and-through"    incision    is    em- 
ployed.     J.    A.    Wyeth     (Med.    Record, 
.June  7,  1902). 
If  the  appendix  is  not  readily  found, 
the   anterior  longititdinal   band   of   the 
caecum  is  taken  as  a  guide  and  followed 
until    the    appendix    is    encountered, — 
usually  behind.     In  the  annexed  colored 
plate  only  the  tip  of  the  appendix  shows; 
but  the  greater  part  of  the  organ  lies 
behind  the  ctecum,  its  orifice  in  the  latter 
being   situated    immediately   itnder   the 
spot  where  the  McBurney  incision   (&) 
crosses  index  line  (e). 

The  peritoneum  completely  surrounds 
the  cfeeum  and  its  appendix.  Treves, 
Talamon  (Amer.  ]Med.  Digest,  June,  Oct., 
and  Nov.,  '90). 

When  the  abdominal  cavity  has  been 
opened  the  exact  position  of  the  appen- 
dix can  be  found  by  following  the  white 
fibrous  bands  along  the  convex  surface 


Lines  of  mcisioninLapaxotoniyforAppendicitis^ 

A.  Umbilicus  B  Cacum  andterminahoncifthE  IleumC  Vermiform  Appendix  D  Anterior  Superior  Spine  oftiie  Ilium 


APPENDICITIS.     OPERATIVE  TECHNIQUE. 


487 


of  the  ctecum  to  the  base  of  the  appen- 
dix. Murphy  (Jour.  Amer.  Med.  Assoc., 
Mar.  30,  '95). 

Experiments  in  operations  and  cadav- 
ers have  shown  that  the  appendix  al- 
ways rises  from  that  point  upon  the 
CEecum  where  the  three  descending  mes- 
enteric bands  join  one  another.  Thus 
by  following  the  anterior  broad  band, 
down  the  caecum,  through  adhesions, 
exudates,  etc.,  the  appendix  is  invariably 
discovered.  P.  Mueller  (Centralb.  f. 
Chir.,  July  6,  1901). 

The  possibility  of  an  anomalous  con- 
formation or  position  of  the  appendix 
should  be  borne  in  mind. 

In  but  three  instances  out  of  one  hun- 
dred and  forty-four  operations  for  dis- 
eases not  connected  with  the  appendix 
was  the  appendix  found  outside  of  the 
peritoneal  cavity.  In  sixty-six  examina- 
tions 40  per  cent,  of  the  appendices  were 
free;  in  that  number  one-half  of  the  en- 
tire length  Avas  surrounded  with  peri- 
toneum. Joseph  D.  Bryant  (Mathews's 
Med.  Quarterly,  '94). 

Case  in  which  tip  of  vermiform  appen- 
dix was  found  in  contact  'with  the  under 
surface  of  liver.  Bland  Sutton  (Med. 
Press  and  Circular,  Oct.  10,  '94). 

In  two  cases  the  appendix  was  found 
attached  to  the  left  Fallopian  tube  and 
bound  up  in  an  adherent  mass  on  that 
side.  In  a  great  number  of  cases  the 
appendix  is  adherent  to  the  Fallopian 
tube  on  the  right  side.  Porter  (Berliner 
klin.  Woch.,  Sept.  4,  '95). 

In  one  hundred  and  fifty  cases  of  post- 
mortem examinations  the  length  of  the 
appendix  varied  from  2  Vs  to  9  %  inches. 
Only  two  came  above  the  general  meas- 
urements: one  6V2,  and  the  other,  the 
longest  the  author  has  been  able  to  find 
any  record  of,  9  Vi  inches.  Both  of  these 
extra-long  appendices  were  found  in 
males.  C.  J.  Eingwell  (Med.  Record, 
July  18,  '96). 

Case  in  which  the  csecum  was  found 
well  toward  the  median  line;  the  ap- 
pendix was  lying  directly  across  the 
abdominal  cavity,  bound  to  the  omen- 
tum in  the  left  iliac  fossa.  M.  M. 
Franklin  (Univ.  Med.  Mag.,  Oct.,  '97). 
If  the  appendix  contain  a  concretion 


or  foreign  body,  or  is  enlarged,  perfo- 
rated, or  otherwise  abnormal,  it  should 
be  tied  close  to  the  caecum,  then  cut  off 
below  the  ligature.  It  is  sometimes 
found  detached  and  necrotic. 

If  there  is  a  circumscribed  abscess,  it 
is  poor  surgery  to  insist,  in  every  case 
and  at  every  period,  upon  finding  and 
taking  away  the  appendix  in  the  face  of 
all  obstacles.  In  many  cases  of  circum- 
scribed abscess,  and  especially  in  those 
in  which  the  appendix  is  bound  down 
by  adhesions  in  the  depth  of  the  wound, 
the  surgeon  should  be  content  with 
evacuation,  irrigation,  drainage,  and 
packing  with  iodoform  gauze.  Persist- 
ent search  for  the  appendix  and  at- 
tempts at  its  removal  in  these  cases  are 
attended  with  such  danger  of  opening 
the  peritoneal  cavity  that  they  are  not 
to  be  recommended.   (J.  William  White.) 

When  circumscribed  peritonitis  and 
abscess  exist  the  indication  is  clearly  to 
drain.  To  persist  in  breaking  up  ad- 
hesions for  the  sake  of  removing  the 
appendix  is  not  wise.  Richardson  (Amer. 
Jour.  Med.  Sciences,  Jan.,  '94) . 

The  appendix  should  be  removed  when 
there  is  no  pus;  when  an  endoappen- 
dicular  abscess  is  present;  as  a  rule, 
when  there  is  a  periappendicular  abscess 
requiring  drainage  through  peritoneal 
cavity;  and  when  there  is  a  general  peri- 
tonitis without  adhesions.  Porter  (Med. 
News,  Sept.  14,  '95). 

There  are  some  cases,  not  few  in  num- 
ber, in  which  the  appendix  is  so  deeply 
imbedded  in  the  wall  of  the  abscess,  or 
so  difficult  to  define  at  all,  that  to  in- 
sist upon  its  discovery  and  complete 
removal  would  be  to  incur  quite  un- 
justifiable risk.  One  had  better  be  con- 
tent with  properly  evacuating,  cleansing, 
and  packing  the  cavity,  leaving  the 
appendix  or  its  remnant  to  be  disposed 
of  by  its  obliteration  in  the  wound- 
healing,  or  by  its  removal  at  a  later  and 
more  favorable  time  through  a  second 
operation.  McBurney  (Univ.  Med.  Mag., 
Mar.,  '96). 


APrENDICITIS.     OPERATIVE  TECHNIQUE. 


It  has  been  my  practice  to  carefully 
evacuate  and  cleanse  by  dry  sponging 
with  sterilized  or  iodoform  gauze  the 
pus-cavity;  then  to  disinfect  its  walls 
with  a  bichloride  solution,  1  to  5000; 
and  then  to  search  for  and  remove  the 
appendix  in  ease  it  be  readily  found  and 
easily  separated  from  the  adhesions.  In 
general,  I  have  found  tliis  feasible  in 
cases  operated  on  up  to  the  seventh  or 
tenth,  day.  In  eases  operated  on  at  a 
later  date,  of  those  where  the  abscess 
is  distinctly  circumscribed  with  firm 
walls  and  containing  several  ounces  of 
pus,  I  have  not  attempted  to  remove 
the  appendix.  Bull  (Univ.  Med.  Mag., 
Mar.,  '96). 

It  has  been  nij'  habit  for  years  in 
cases  of  acute  appendicitis  with  exten- 
sive suppuration  to  simply  incise,  dis- 
infect, and  drain  the  abscess,  unless  the 
diseased  appendix  could  be  removed 
without  any  additional  risk.  I  have 
seen  a  number  of  such  cases  recover  per- 
manently without  any  additional  sur- 
gical interference.  I  regard  persistent 
search  for  the  appendix  in  such  cases 
hazardous,  as  it  often  results  in  opening 
of  the  free  peritoneal  cavity  and  fatal 
septic  peritonitis.  Senn  (Univ.  Med. 
Mag.,  Mar.,  '96). 

In  cases  of  appendicitis  in  which  the 
appendix  is  found  to  be  densely  ad- 
herent, or  when  it  opens  into  an  abscess, 
or  when  there  exists  a  more  or  less  gen- 
eral peritonitis,  the  operator  dreads  all 
avoidable  contamination  of  the  sur- 
rounding tissues  with  any  part  of  the 
appendiceal  abscess,  and  all  avoidable 
injury  to  the  coats  of  the  adherent  in- 
testine. When  the  appendix  is  diseased 
and  densely  adherent  at  its  tip,  the 
best  plan  often  is  first  to  seek  out  and 
expose  its  base,  which  is  detached  and 
divided  so  as  to  free  the  appendix  from 
the  caecum.  The  distal  portion  is  now 
wrapped  for  protection  in  gauze,  while 
the  opening  into  the  bowel  is  closed. 
Then  the  severed  appendix  is  dissected 
out  of  its  bed  with  much  greater  facility 
than  was  possible  with  both  ends  an- 
chored, one  to  the  caecum  and  one  to 
the  adhesions.  This  plan  of  procedure 
is  especially  useful  in  the  gynaecological 
field.     In  cases  in  which  the  vermiform 


appendix  is  attached  to  a  pyosalpinx,  or 
an  ovarian  or  fibroid  tumor,  after  it  is 
severed  from  the  bowel,  it  can  then  be 
enucleated  with  the  pelvic  abscess  or 
with  the  tumor.  When  the  end  of  the 
appendix  enters  the  abscess  cavity  sur- 
rounded by  the  adherent  intestine, 
which  cannot  be  stripped  off  with 
safety,  after  freeing  the  base  of  the  ap- 
pendix from  caecum  it  was  traced  up 
until  it  entered  an  abscess-cavity  under 
the  ascending  colon.  It  could  not  be 
separated  from  the  adhesions  without 
injuring  the  bowel,  so  the  appendix  was 
grasped  with  a  pair  of  forceps,  on  either 
side,  close  to  the  abscess,  and  split  open 
and  followed  to  its  lumen,  as  a  guide,  by 
using  a  grooved  director  and  a  pair  of 
open  scissors,  with  one  blade  in  the  ap- 
pendix. The  operator  was  thus  enabled 
with  certainty  to  enter  tlie  very  middle 
of  the  abscess-cavity,  and  to  lay  it  open 
and  cleanse  it  without  doing  any  dam- 
age to  the  colon.  H.  A.  Kelly  (Phila. 
Med.  Jour.,  from  Amer.  Medicine,  Apr. 
20,  1901). 

The  stump  is  either  simply  disinfected 
or  the  mucous  membrane  of  cut  surface 
cauterized  with  carbolic  acid  or  cautery. 
The  latter  procedure  is  generally  unnec- 
essary, however.  If  the  tissues  about  the 
base  of  the  appendix  are  nearly  normal, 
it  is  better  to  invert  the  stump  and  close 
it  with  two  or  three  Lembert  siTtures. 

The  methods  of  dealing  with  the  stump 
at  present  employed  are  far  from  perfect. 
After  removing  the  appendix  a  contin- 
ous  Lembert  suture  should  be  run 
around  the  appendix  like  a  purse-string. 
The  appendix  is  then  divided,  leaving  the 
stump  never  shorter  than  one-half  inch. 
The  stump  is  then  invaginated, — turned 
"outside  in,"  as  a  glove-finger, — the  ap- 
pendix end  thus  being  inserted  one-half 
inch  inside  the  caecum.  Dawbarn  (Inter. 
Jour,  of  Surg.,  vol.  viii.  No.  8). 

In  whatsoever  manner  treated,  the 
stump  remains  as  an  excrescence,  with 
chances  of  adhesions.  To  eliminate 
these,  inversion  into  the  lumen  of  the 
large  intestine  of  either  the  entire  ap- 
pendix or  any  part  remaining  attached 
to  the  caput  coli  is  recommended.     Ede- 


APPENDICITIS.     OPERATIVE  TECHNIQUE. 


489 


bohls  (Amer.  Jour.  Med.  Sciences,  June, 
'95). 

Inversion  of  the  uncut  appendix  obvi- 
ates the  necessity  of  opening  the  bowels 
and  avoids  the  risk  of  infection.  Per- 
sonally practiced  in  more  than  one  hun- 
dred cases.  In  performing  the  operation 
the  appendi.x  is  freed  from  all  adhesions 
and  brought  into  view  in  the  usual  way. 
The  tip  of  the  appendix  is  held  by  an 
assistant,  who  with  the  thumb  and  fore- 
finger of  the  other  hand  supports  the 
colon  edges  below  the  origin  of  the  ap- 
pendix. The  ligature  is  then  introduced 
and  the  meso-appendix  ligated,  which  is 
then  severed  just  beyond  the  ligature. 
The  appendix  is  then  freed  of  its  peri- 
toneal coat.  The  appendix,  having  thus 
been  prepared  for  inversion,  is  seized  be- 
tween the  thumb  and  forefinger  of  one 
hand  and  inverted  by  pressing  upon  it 
with  the  blunt  end  of  a  needle.  The 
mucous  membrane  having  been  inverted 
for  some  distance,  the  needle  is  substi- 
tuted by  a  long  probe,  Avhich  easily  com- 
pletes the  inversion.  A  single  stitch  is 
then  taken,  closing  the  opening  in  the 
bowel,  which  then  marks  the  point  of 
opening  of  the  appendix.  In  a  few  cases 
in  which  operation  is  made  for  appendi- 
citis inversion  is  impossible  or  so  difficult 
as  to  be  unwise.  These  cases  include 
gangrene  of  the  appendix  and  those  in 
which  there  is  a  constriction  near  its 
base.  J.  F.  Baldwin  (Med.  Record,  Jan. 
20,  1900). 

Drainage  is  to  be  maintained  until 
healing  is  shown  to  be  taking  place  from 
the  bottom  of  the  wound.  Gauze  is  to 
be  used  not  only  for  the  purpose,  but 
quite  as  much  to  stimulate  the  adhesions 
between  coils  of  intestine  which  sur- 
round it  and  to  shut  off  the  general  peri- 
toneal cavity  from  the  infected  portion. 
(Halsted.) 

The  Mikulicz  drain,  a  bundle  of  lamp- 
wicks,  is  an  exceedingly  potent  means 
of  producing  drainage.  Wood  (N.  Y. 
Med.    Jour.,    May,    '95). 

Analysis  of  twelve  hundred  and  thirty- 
six  cases  of  appendicitis  operated  on  in 
the  Massachusetts  General  Hospital  and 


examined  some  time  after  operation. 
Many  of  the  cases  which  reported  them- 
selves as  perfectly  well  had  marked  gen- 
eral bulging  of  the  abdominal  wall  on 
the  side  operated  upon.  Some  had  pro- 
trusions of  the  wound,  and  some  had 
hernias  of  which  they  were  not  aware. 
Intermuscular  spaces  could  be  detected 
in  28  per  cent,  of  those  with  tightly 
closed  wounds.  These  were  present  in 
S3  per  cent,  of  those  eases  with  wounds 
tightly  closed  and  87  per  cent,  of  those 
which  were  left  open.  These  intermus- 
cular spaces  result  from  separation  of  the 
muscles  which  were  not  brought  into  ap- 
position by  sutures.  Drainage  by  gauze 
or  by  other  means  favors  this  condition, 
as  do  also  transverse  Incisions  of  the 
muscles.  The  muscular  and  tendinous 
fibres  should  not  be  cut  in  any  appendix 
operations  if  it  can  be  avoided.  When 
drainage  is  necessary,  as  much  of  the 
wound  should  be  closed  as  possible  with 
sutures,  and  the  drainage  removed  at 
the  earliest  moment  consistent  with 
safety.  Stout  belts  and  trusses  are  of 
little  value  in  the  after-treatment  of 
these  cases,  and  may  even  do  harm.  The 
abdominal  muscles,  from  the  earliest  pos- 
sible period  after  the  operation,  should 
be  developed  with  proper  exercises.  If 
hernia  or  marked  bulging  occurs,  an 
operation  for  radical  cure  is  safe  and 
satisfactory.  F.  B.  Harrington  (Boston 
Med.  and  Surg.  Jour.,  Aug.  .3,  '99). 

Appendix  removed  while  performing 
adjacent  abdominal  operations  whenever 
it  shows  signs  of  inflammation  or  thick- 
ening. Medical  treatment  is  useless 
and  opium  should  never  be  given.  A 
total  of  68  eases  shows  that,  the  more 
carefully  drainage  is  insured,  stitches  in 
the  abdominal  wall  omitted,  and  the 
longer  the  abdomen  is  kept  open,  the 
more  successful  is  the  result.  E.  Rose 
(Deutsche  Zeit.  f.  Chir.,  Mar.,  1901). 

It  is  important  to  withdraw  the  gauze 
plugs  by  rotary  movement  rather  than 
by  direct  traction;  it  causes  less  pain. 
The  patient  should  be  revived  from  the 
shock  of  the  operation  as  early  as  pos- 
sible by  an  enema  of  hot  coffee  or  whisky. 
(Abbe.') 


490 


APPENDICITIS.     OPERATIVE  TECHNIQUE. 


Two  cases  in  which  a  circumscribed 
abscess  was  drained^  and  a  sinus  per- 
sisted until  the  appendix  was  removed, 
some  months  later.  Removal  of  the  ap- 
pendix performed  through  an  incision 
parallel  to  one  internal  to  the  original 
one.  The  sinus,  unopened,  was  followed 
down  to  the  appendix,  which  was  -  re- 
moved after  the  healthy  parts  had  been 
carefully  walled  off.  All  sinuses  in  the 
neighborhood  of  the  appendix  should  be 
approached  in  this  way.  It  is  easier  to 
prevent  infection  of  the  peritoneum  if 
the  cavity  be  freely  opened  so  that  the 
healthy  parts  may  be  protected  and  the 
situation  of  the  appendix  defined,  than 
if  the  surgeon  attempts  to  follow  the 
sinus  from  the  first,  not  knowing  ex- 
actly where  he  may  open  the  peritoneal 
cavity.  Collins  Warren  (Boston  Med. 
and  Surg.  Jour.,  Oct.  28,  '90). 

Eemote  Abscesses.  —  While  the  ma- 
jority of  abscesses  are  found  in  the  ap- 
pendicular region,  others  may  occupy 
areas  quite  remote  from  the  latter.  To 
properly  locate  such  an  abscess  is  of 
great  importance.  "When  their  evacua- 
tion becomes  necessary  the  selection  of 
the  best  point  for  incision  is  in  order. 
This  subject  is  graphically  portrayed  in 
the  annexed  colored  plate  prepared  from 
sketches  and  an  interesting  paper  pub- 
lished by  Dr.  M.  L.  Harris. 

Description  of  Colored  Plate  on  the 
Location  of  Appendicular  Abscesses. — 
A  circle  of  an  inch  and  a  half  in  diameter, — 
the  size  of  a  silver  dollar, — drawn  about  the 
centre  of  the  posterior  surface  of  the  caecum, 
will  touch  the  base  or  point  of  origin  of  the 
appendix  in  about  96  per  cent,  of  all  cases. 
It  will  thus  be  seen  how  constant  is  the  loca- 
tion of  the  base  of  the  appendix.  The  average 
length  of  the  adult  appendix  is  nine  centi- 
metres, or  three  and  one-half  inches.  A  circle 
then,  of  four-inch  radius,  drawn  about  the 
same  centre  as  the  smaller  circle,  Avill  give  a 
very  large  area  in  the  abdominal  cavity,  any- 
where within  which  the  apex  of  the  normal 
appendix  may  be  found  located.     (See  Fig.  1.) 

The  space  within  the  large  circle  (see  Fig. 
2)  may  be  subdivided  into  five  separate  areas 
(marked  1,  2,  3,  4,  and  5),  each  having  dis- 


tinct and  well-defined  boundaries.  The  appen- 
dix may  be  found  in  any  one  of  these  areas, 
and,  when  an  abscess  forms  about  the  in- 
flamed organ,  it  is  the  particular  area  in 
which  the  appendix  is  located  which  gives  the 
abscess  or  exudate  its  characteristic  location 
and  outline,  which  limits  its  extension  in  one 
direction  and  favors  it  in  another,  and  which 
should  guide  us  in  the  selection  of  the  best 
point  for  incision. 

Area  I:  Infra-mesenteric. — The  appendix  is 
met  with  in  this  area  in  about  60  per  cent, 
of  the  cases,  either  superficially  situated, 
approaching  anteriorly,  or  lying  deeply  on  the 
posterior  wall;  it  may  extend  directly  inward, 
hugging  the  under  surface  of  the  mesentery 
at  the  ileum,  or  inward  and  downward,  reach- 
ing often  into  the  true  pelvis.  The  mesentery 
above  prevents  the  extension  of  abscesses  in 
an  .upward  direction,  but  gives  them  a  tend- 
ency to  extend  forward  and  to  the  left. 

The  pelvic  abscesses  are  limited  in  the  male 
anteriorly  by  the  bladder,  posteriorly  by  the 
rectum  and  pelvic  wall  and  above  by  the  sig- 
moid and  loops  of  small  intestine.  In  the 
female  they  fill  Douglas's  cul-de-sac  or  occupy 
the  ovarian  region  on  one  or  both  sides, 
where  they  are  often  with  great  difficulty 
differentiated  from  pelvic  abscesses  of  tubal 
or  ovarian  origin.  The  danger  of  infecting 
the  general  cavity  on  opening  these  abscesses 
from  above  is  very  great,  and  the  advisability 
of  draining  through  the  vagina  in  the  female, 
as  in  other  septic  pelvic  troubles,  comes  into 
serious  consideration. 

The  inter-intestinal  abscesses  (see  also  Figs. 
3  and  4)  are  usually  situated  near  the  median 
line,  and  are  consequently  best  opened  at  this 
point.  Adhesions  may  limit  them,  or  there 
may  be  no  adhesions  and  the  free  peritoneal 
cavity  must  be  traversed  to  reach  the  abscess, 
after  packing  with  iodoform  gauze  to  prevent 
diffusion  of  pus.  It  is  often  impossible  to 
prevent  pus  escaping  into  the  general  cavity, 
with  a  resulting  fatal  acute  septic  peritonitis. 
It  is  in  those  cases  that  the  advisability  of 
doing  a  deux  temps  operation  should  be  con- 
sidered. Should  the  appendix  be  found  float- 
ing free  in  the  abscess-cavity  it  may  be  re- 
moved, but  if  it  be  firmly  imbedded  in  the 
exudate  forming  part  of  the  abscess-wall  it 
should,  under  no  circumstances,  be  torn  out 
and  removed,  if  by  so  doing  we  endanger 
breaking  into  the  general  cavity,  thus  leading 
to  general  sepsis. 


Location  of  Appendicular  Abscess,  (ML, Hams.) 

a  Anterior  Superior  Spine  of  the  Ilium,  b.Umbillicus,  c.  Symphysis,  d,  Pouparts  ligament. 


APPENDICITIS.     OPERATIVE  TECHNIQUE. 


491 


The  exudate  may  also  come  to  the  surface, 
forming  adhesions  to  the  anterior  abdominal 
wall,  just  internal  to  the  caecum.  (See  Fig. 
5.)  The  abscess  is  limited  externally  by  the 
caecum  and  internally  by  the  loop  of  ileum 
which  almost  always  covers  over  the  end  of 
the  cascum  and  the  omentum.  It  is  usually 
best  opened  by  a  vertical  incision  over  the 
inner  border  of  the  cascum.  Care  should  be 
taken  not  to  separate  the  loop  of  intestine  in- 
ternally, particularly  at  its  lower  angle,  as 
pus  then  escapes  at  once  into  the  pelvis.  The 
appendix  can  nearly  always  be  removed,  as 
it  usually  lies  posteriorly  or  anteriorly,  and  it 
can  be  done  without  disturbing  the  internal 
wall  of  exudate  which  protects  the  general 
cavity. 

Area  2:  Betro-ccccal. — Abscess  is  met  in 
this  area  (see  also  Fig.  6)  in  about  23  per  cent, 
of  the  cases.  The  appendix  lies  in  the  little 
pouch  posterior  to  the  caecum,  more  or  less 
curved  or  folded  upon  itself  or  extending 
downward  and  outward. 

It  is  best  opened  by  an  oblique  incision 
parallel  to  the  outer  half  of  Poupart's  liga- 
ment, coming  down  upon  the  outer  border  of 
the  CEeeum,  which  should  be  raised  up  and 
turned  inward.  The  appendix  can  nearly 
always  be  removed,  unless  it  should  be  too 
firmly  imbedded  in  the  exudate  forming  the 
inner  wall. 

Area  3:  Supra-meseiiteric. — Abscesses  here 
(see  also  Fig.  7)  have  a  tendency  to  spread 
toward  the  liver  and  duodenum.  The  appendix 
lies  above  the  mesentery  of  the  ilium  and  in- 
ternal to  the  inner  layer  of  the  mesocolon. 

These  abscesses  are  best  reached  by  an  in- 
cision along  the  external  border  of  the  right 
rectus  muscle,  great  care  being  taken  not  to 
break  down  the  adhesions  between  the  loop 
of  small  intestine  to  the  inner  side.  (See  in- 
cision c  in  first  colored  plate.) 

Area  4:  External. — This  is  the  space  be- 
tween the  outer  border  of  the  colon,  with  its 
outer  layer  of  mesocolon,  and  the  external 
abdominal  wall.  The  appendix  may  extend 
upward  and  outward  into  this  space,  its  tip 
sometimes  reaching  nearly  to  the  under  sur- 
face of  the  liver.  Abscesses  spread  to  the  liver 
and  have  repeatedly  ruptured  into  the  pleura 
and  even  Into  the  bronchi.     (See  Fig.  8.) 

They  may  be  reached  by  an  oblique  incision 
extending  from  above  the  crest  nf  the  ilium 
downward  and  inward,  parallel  to  the  outer 
third  of  Poupart's  ligament;    or,  if  the  abscess 


is  high  up,  by  a  longitudinal  incision  over  its 
most  prominent  part,  care  being  taken  to  not 
injure  the  ilio-hypogastric  nerve.  The  appen- 
di.x  can  nearly  always  be  removed,  as  there 
is  no  danger,  in  separating  the  adhesions 
about  it,  of  opening  the  general  cavity. 

Area  5:  Retro-colonic,  or  Extra-peritoneal. 
— In  the  cellular  space  posterior  to  the  colon 
between  the  two  layers  of  the  mesocolon. 
(See  Fig.  9.)  Abscesses  here  are  entirely  extra- 
peritoneal.    The  colon  is  pushed  forward. 

The  incision  in  these  cases  should  be  an 
oblique  one,  similar  to  the  one  described  under 
the  fourth  area,  but  extending  pretty  well 
above  the  crest  of  the  ilium.  M.  L.  Harris 
(.Journal  of  the  Amer.  Med.  Assoc,  Dec.  21, 
'95). 

In  retrocsecal  suppurative  appendicitis 
an  incision  recommended  along  the  ex- 
ternal border  of  the  sacro-lumbar  mass 
of  muscle,  and  extending  forward  at  the 
lower  extremity  parallel  to  and  at  a 
distance  of  about  an  inch  from  the  crest 
of  the  ilium  to  within  a  distance  of 
about  an  inch  and  one-fourth  from  the 
antero-superior  iliac  spine.  The  signs  of 
retrocEBcal  abscess  are  the  following: 
Tenderness  over  the  triangle  of  Petit; 
but  little,  if  any,  pain  at  McBurney's 
point;  marked  fullness  in  the  right 
flank;  and  a  clear  sound  on  percussing 
the  right  iliac  fossa.  If  the  appendix 
be  found  on  one  side  or  in  the  front  of 
the  cfficum,  it  may  still  be  readily  ex- 
posed by  this  incision.  The  situation 
of  the  wound  permits  perfect  drainage 
and  tends  to  secure  the  patient  against 
the  subsequent  risk  of  hernia.  Grinda 
(Med.  Mod.,  No.  71,  '97). 

Out  of  a  total  of  600  cases  of  appen- 
dicitis (350  with  abscess-formation)  in 
Sonnenburg's  hospital  and  private  prac- 
tice, the  complication  of  subphrenic  ab- 
scess was  met  with  in  9.  In  6  of  these 
the  appendix  and  caecum  were  displaced 
beneath  the  liver;  so  that  the  suppura- 
tion passed  directly  into  the  subphrenic 
space,  extraperitoneally  in  1  case,  intra- 
peritoneally  in  the  majority.  Pyothorax 
was  also  present  in  6  cases;  there  was 
dry  pleurisy  at  the  base  of  the  lung  and 
of  the  diaphragmatic  pleura  in  2  cases. 
The  subphrenic  abscess  is  easily  opened 
and  drained  when  it  comes  to  the  front 
below  the  costal  margin;    when  it  devel- 


492 


APPENDICITIS.    RELAPSING  FORM. 


ops  posteriorly,  it  must  be  approached 
by  the  transthoracic  route.  The  rarity 
of  subphrenic  abscess  in  so  large  a  num- 
ber of  cases  of  appendicitis  is  ascribed 
to  the  treatment  of  the  latter  by  opera- 
tion at  a  relatively  early  period  of  the 
disease.  Korte  has  operated  on  35  eases 
of  subphrenic  abscess,  no  less  than  16  of 
which  were  the  result  of  appendicitis. 
Weber  (Centralb.  f.  Chir.,  Mar.  10,  1900). 

Diffuse  Abscess. — If  an  abscess  has 
opened  into  the  peritoneal  cavity,  caus- 
ing diffused  septic  peritonitis,  a  good- 
sized  incision  is  made  parallel  to  the 
border  of  Poupart's  ligament,  the  peri- 
toneal eavity  is  opened,  and  the  con- 
tained fluids  are  removed.  The  appen- 
dix is  removed;  further  collections  of 
fluid  are  looked  for  and  withdrawn  with 
a  sponge  on  a  handle.  The  cavity  is 
washed  out  with  a  saline  solution  and 
drainage  is  provided  for  by  a  glass  tube 
with  a  capillary  gauze  drain.  The  wound 
is  left  open,  but  no  suturing  is  practiced. 
jSTutrition  by  rectum  for  a  day  or  two. 
The  deep  packing  is  not  disturbed  for 
four  days.     (McBurney.) 

In  twenty-four  cases  treated  by  the 
above  procedure  fourteen  recoveries  ob- 
tained. McBurney  (N.  Y.  Med.  Record, 
Mar.  30,  '95). 

Eelapsing  Form. 

Symptoms. — The  symptoms  of  an  ex- 
acerbation are  the  same  as  in  the  acute 
form.  The  simple  catarrhal  form  may  be 
suspected  when  the  recurrences  happen 
more  than  four  or  five  times,  and  last 
not  more  than  a  week  and  no  tumor  is 
felt. 

The  ulcerative  form  with  its  attend- 
ing danger  of  perforation  may  be  sus- 
pected when  a  tumor  is  felt  in  the  inter- 
val, and  especially  when  the  tumor  has 
increased  in  size  during  the  access. 

In  fifty-seven  cases  of  simple  appendi- 
citis, fifty-two  showed  appendicular  per- 
foration with  abscess  of  surroundings. 
In  eighty  cases  twenty  presented  at  least 


one  previous  attack.     Mathieu,  Sonnen- 
burg  (Gaz.  des.  Hop.,  Dec.  18,  '94). 

Perforation  the  rule  in  recurrent  cases; 
the  adhesions  rupture,  often  without  giv- 
ing any  sign,  the  patient  dying  of  sub- 
acute peritonitis.  Several  instances  in 
eases  supposed  to  be  cured.  Broca  (Bull, 
de  la  Soc.  Anat.,  Dec,  '94) . 

Etiology  and  Pathology.  —  The  large 
majority  of  the  attacks  are  due  to  any 
cause  which  may  awaken  the  latent  catar- 
rhal process  resulting  from  a  previous 
attack  treated  medically.  The  patholog- 
ical characters  are  the  same  as  in  the 
acute  form,  except  in  the  fact  that  adhe- 
sions are  likely  to  be  found  if  anything 
but  a  very  mild  attack  has  previously 
occurred. 

There  is  a  class  of  cases,  "appendicitis 
obliterans,"  a  comparatively  frequent 
relapsing  form,  which  is  characterized  by 
progressive  obliterations  of  the  lumen  of 
the  appendix.  Ribbert  found  in  four 
hundred  post-mortems  (death  being  due 
to  other  causes  than  appendicitis)  par- 
tial or  complete  obliteration  in  25  per 
cent.  Senn  (Jour.  Amer.  Med.  Assoc, 
Mar.  24,  '94). 

Instances  in  which  there  is  only  one 
attack  are  much  more  numerous  than 
those  in  which  there  have  been  several 
attacks.  The  great  majority  of  those 
who  have  passed  through  the  stage  of 
suppuration  are  rendered  free  from  fur- 
ther attacks.  Treves  (Brit.  Med.  Jour., 
Mar.  9,  '95). 

After  one  attack  the  appendix  is  fre- 
quently as  fully  capable  of  originating 
another  attack.  Stimson,  Bryant,  Fow- 
ler (Annals  of  Surgery,  May,  '95). 

1.  The  chief  agents  in  producing  re- 
lapsing or  recurrent  appendicitis  are 
micro-organisms  latent  in  the  thick 
walls  of  the  vermiform  appendix,  in  the 
strictures,  and  in  the  cicatricial  tissue, 
and  adhesions  both  periappendicular  and 
parietal. 

2.  Alteration  and  enfeeblement  of  the 
walls  of  the  appendix;  as  by  infiltration 
of  fat,  and  new  formation  and  dilatation 
of  vessels,  which  readily  favor  both  act- 


APPENDICITIS.     RELAPSING  FORM. 


493 


ive  and  passive  congestion  or  add  to  the 
results. 

3.  Certain  appendices,  apparently 
"healed,"  have  some  abrasion  of  the  mu- 
cous membrane,  which  easily  explains 
the  presence  of  bacteria  in  the  tissues, 
and  by  their  development  a  reinfection 
is  occasioned.  Ch.  von  Mayer  (Revue 
Med.  de  la  Suisse  Rom.,  Apr.  20,  '97). 

In  almost  all  chronic  cases  unattended 
by  abscess  or  inflammatory  adhesions, 
there  is,  first,  a  bend,  or  flexure,  of  the 
appendix;  second,  at  the  point  of  flexure 
there  is  also  a  stricture;  and,  third,  dis- 
tal to  the  stricture  is  marked  distension 
of  the  appendix  and  great  thickening  of 
its  walls.  Supposing  that  the  bend  in 
the  appendix  is  the  first  step  in  appen- 
dicitis, the  bend  embarrasses  the  escape 
of  contents.  To  empty  itself,  the  mus- 
cular walls  are  compelled  to  perform 
extra  work,  producing  a  very  marked 
muscular  hypertrophy.  As  a  result  of 
the  pressure  caused  by  the  effort  of  the 
appendix  to  empty  itself,  the  mucous 
coat  at  the  point  of  flexion  becomes 
eroded  and  inflamed,  and  functional 
stricture  finally  terminates  in  an  organic 
stricture.  This  gives  rise  to  recurring 
attacks  of  pain,  which  ceases  when  the 
appendix  has  discharged  its  contents. 
After  a  time,  the  organ  is  no  longer  able 
to  empty  itself.  Distension,  perforation, 
and  peritonitis  then  follow.  D.  P.  Allen 
(Med.  Record,  June  5,  '97). 

Forty-five  cases  of  appendicitis  com- 
plicating pregnancy,  diagnosis  being  con- 
firmed in  thirty  by  operation  or  post- 
mortem. It  is  concluded  that:  1.  Ap- 
pendicitis may  attack  a  pregnant  woman 
at  the  beginning  or  at  any  time  during 
pregnancy  in  the  puerperium.  2.  In  most 
cases  it  causes  abortion.  The  child  dies, 
as  a  rule,  very  rapidly  from  infection. 
3.  It  is  only  possible  to  save  both  mother 
and  child  when  the  abscess  is  limited  and 
encysted.  4.  Every  type  of  appendicitis 
may  occur.  5.  The  diagnosis  may  be 
difficult,  owing  to  the  enlarged  uterus, 
or  still  more  so  during  the  puerperium, 
but  is  usually  possible  with  care.  6. 
Treatment  consists  in  operating  as  early 
as  possible.  A  preliminary  induction  of 
premature  labor  is  unjustifiable,  since 
pregnancy   is  not  always   interrupted   if 


the  mother  recovers.  7.  Prophylaxis  con- 
sists in  operating  in  every  case  of  re- 
lapsing appendicitis  in  a  j'oung  girl  or 
non-pregnant  woman  during  the  period 
of  sexual  activity.  Pinard  (La  Sem. 
Med.,  Mar.  23,  '98). 

Prognosis.  —  The  chances  that  a  first 
or  second  attack  of  acute  catarrhal  ap- 
pendicitis will  be  renewed  are  about  77 
per  cent.;  but,  when  a  fourth  or  a  fifth 
attack  has  occurred,  the  probability  is 
very  great  that  more  will  follow  and 
ultimately  end  fatally,  unless  operation 
is  performed. 

After  the  patient  has  gone  through  an 
acute  attack  safely,  and  the  characteristic 
tumor  indicating  an  acute  suppurative 
process  is  felt,  a  circumscribed  perito- 
nitis, rather  than  a  general  suppurative 
one,  is  likely  to  occur  if  another  attack 
takes  place. 

Analysis  of  50  cases  of  recurrent  ap- 
pendicitis operated.  Thirty-nine  were 
males  and  11  were  females.  Twenty- 
three  occurred  in  persons  between  20 
and  30  years  of  age.  The  youngest 
patient  was  10  and  the  oldest  53  years 
of  age.  In  only  5  patients  had  there 
been  but  one  distinct  attack.  In  almost 
every  case  the  lumen  of  the  appendix 
was  either  partially  or  completely  oc- 
cluded at  some  point  in  its  course.  In 
6  cases  fsecal  concretions  were  present, 
but  in  no  instance  was  any  foreign  body 
found.  All  recovered.  Southam  (Brit. 
Med.  Jour.,  Jan.  10,  1903). 

Surreal  Treatment.  —  This  is  indi- 
cated when  the  relapses  are  frequent  and 
increasing  in  severity,  and  when  a  tumor 
is  present  during  the  interval,  the  pres- 
ence of  septic  accumulation,  ulceration, 
or  perforation  being  likely.  It  should  be 
performed  during  a  period  of  quiescence 
in  the  manner  described  in  the  preceding 
pages. 

In  relapsing  cases  the  operation  should 
be  performed  between  the  attacks.  Roux 
(Revue  Med.  de  la  Suisse  Rom.,  Sept., 
Oct.,  Nov.,  '91;    Jan.,  '92). 


494 


APPENDICITIS.     AFTER-TREATMENT  OF  THE  VARIOUS  FORMS. 


The  general  consensus  of  opinion  favors 
operation,  both  in  latent  eases  Avith  re- 
lapse and  those  which  are  accompanied 
by  a  general  purulent  peritonitis.  Rficlus 
(La  Semaine  Med.,  June  22,  '92). 

Prompt  surgical  interference  during 
the  interval  between  the  attacks  is  an 
advisable  and  safe  procedure.  The  phys- 
ical characteristics  define  clearly  the 
situation  of  the  appendix.  Bryant  (Jour. 
Amer.  Med.  Assoc,  Nov.  3,  '94). 

Fifty-one  cases  of  recurrent  appendi- 
citis operated  during  intervals  between 
attacks,  with  but  one  death.  Conserva- 
tism should  be  observed,  however,  about 
operating  during  an  acute  attack.  There 
is  no  distinction  between  simple  appen- 
dicitis and  appendicitis  with  perforation, 
as  far  as  operative  indications  go.  Kum- 
mel  (Le  Bull.  Med.,  Oct.  G,  '95). 

Four  cases  of  chronic  appendicitis,  in 
each  of  which  operation  was  clearly  in- 
dicated and  had  been  advised  by  several 
eminent  surgeons,  successfully  treated  by 
"tonic"  doses  of  protiodide  of  mercury. 
Horwitz  (Annals  of  Surg.,  Jan.,  '98). 

The  most  suitable  time  for  operation 
is  about  three  weeks  after  the  commence' 
ment  of  the  attack,  when  all  acute  symp 
toms  have  disappeared  and  the  tempera- 
ture and  pulse  have  become  normal.  G, 
Barling  (Brit.  Med.  Jour.,  Jan.  29,  '1 

Conclusions  are  that  in  all  cases  of 
appendicitis  during  the  first  attack,  oper 
ation  should  not  be  performed  unless  sup- 
puration  or  diffuse  peritonitis  requires  it. 
In  lapsing  or  recurrent  cases,  in  which  it 
is  probable  that  distortion  or  other  per 
nianent  injury  to  the  appendix  exists, 
one  should  operate.  E.  D.  Ferguson 
(N.  Y.  Med.  Jour.,  Mar.  26,  '98). 

According  to  Czerny,  the  first  acute 
attack  of  appendicitis  belongs  to  the 
physician.  This  attack  may:  {«)  pass 
by  without  complication,  in  which  case 
there  is  no  occasion  for  surgical  inter- 
ference; or  (6)  earlier  or  later,  with 
alarming  symptoms  of  general  or  local 
nature  (fever,  rapid  pulse,  pain,  dullness 
on  percussion,  rigidity),  it  may  go  on  to 
perforation  and  abscess-formation.  Such 
an  abscess  either  (A)  leads  to  progressive 
and  threatening  general  peritonitis  or 
(B)  it  remains  circumscribed  and  be- 
comes    incapsulated,     the     first     severe 


symptoms  continuing  without  important 
change.  The  conditions  (6),  (A),  and 
{B)  indicate  surgical  treatment,  as  do  all 
chronic  recurrent  forms  of  appendicitis, 
whether  they  be  purely  catarrhal,  ulcer- 
ative, perforating,  or  obliterative.  Edi- 
torial (Phila.  Med.  Jour.,  July  9,  '98). 

After-treatment  of  the  Various  Forms. 

— The  patient  should  not  leave  his  bed 
until  the  subsidence  of  all  trace  of  in- 
flammation and  until  proper  healing  of 
the  wound  have  taken  place,  namely: 
from  three  to  five  weeks.  Otherwise 
there  is  great  liability  to  recurrence  or 
relapse. 

The  after-treatment  is  important  and 
should  be  conducted  with  great  care. 
The  stomach  should  be  given  complete 
rest  for  twelve  hours,  cracked  ice  and 
water  being  allowed  in  moderation.  Af- 
ter that,  liquid  food,  beginning  with 
peptonized  milk,  if  there  is  any  tendency 
to  nausea  or  vomiting,  may  be  given.  To 
keep  the  intestinal  tract  as  clear  as  pos- 
sible, a  daily  injection  of  lukewarm  soap 
and  water  is  sufficient.  The  patient 
should  lie  on  his  back  the  first  four  days, 
then  begin  to  change  his  positions  in  bed, 
if  he  desires,  without  violence.  Opium 
should  be  given  in  small  doses:  just 
enough  to  check  peristalsis. 

The  outside  dressing  should  be  changed 
every  day  at  first,  and  the  packing  re- 
moved on  the  fourth  or  fifth  day  after 
operation.  This  should  be  done  with 
great  care  and  the  cavity  cleansed  by  dry 
sponging,  no  fluids  being  introduced  into 
the  wound.  The  woimd  is  then  repacked 
and  left  so  three  days,  and  renewed  when 
necessary.  As  the  packing  is  renewed 
from  time  to  time,  it  should  be  reduced 
in  size  at  each  sitting  so  as  to  permit  the 
wound  to  heal  from  the  bottom. 

Apart  from  the  actual  tearing  of  ad- 
hesions or  bowel  by  violent  exercise,  it  is 
clear  that  great  exertion  or  strain  before 
the  adhesions  are  properly  organized  and 


APPENDICITIS. 


ARGONIN. 


495 


tougli  might  lead  to  their  stretching  so 
as  to  form  elongated  bands,  which  may 
subsequently  tend  to  intestinal  obstruc- 
tion. 

It  is  therefore  obviously  prudent  to  im- 
press upon  patients  the  necessity  for 
moderation  in  violent  exercise  for  at 
least  one  year  from  the  time  of  the  oper- 
ation. William  H.  Bennett  (Clinical 
Jour.,  Sept.  7,  '98). 

After  a  second  catarrhal  attack  the 
operation  for  removal  of  the  appendix 
when  possible  ought  to  be  done  after  all 
acute  sj'mptoms  have  subsided,  and 
after  the  patient  has  been  carefully  pre- 
pared for  it.  The  diet  for  four  days 
ought  to  consist  of  soups,  barley-water, 
and  white  meats,  avoiding  milk  and 
starchy  foods.  The  bowels  should  be 
regulated  so  that  they  are  thoroughlj' 
moved  the  day  before  operation.  The 
•  usual  arrangements  for  the  preparation 
of  the  skin  are  carried  out,  3  ounces  of 
soup  with  a  tablespoonful  of  whisky  are 
given  as  a  nutrient  enema  three-fourths 
of  an  hour  before  operation,  and  a  sub- 
cutaneous injection  of  V30  grain  of 
strychnine  which  materially  diminishes 
shock,  and  this  may  be  repeated  in  the 
middle  of  the  operation  if  necessarj'. 
An  incision,  varying  in  length  from  2  to 
3  inches  according  to  the  stoutness  of 
the  patient,  is  made  on  the  outer  side 
of  the  rectus  muscle  over  McBurney's 
point,  dividing  skin  and  fascia,  the  mus- 
cles are  then  separated,  not  cut,  and  the 
peritoneal  cavity  carefully  opened  in 
the  usual  way,  a  small  sponge  with 
string  attached  is  introduced  into  the 
abdomen,  all  small  vessels  are  then  tied 
in  order  to  get  rid  of  the  pressure- 
forceps  in  the  neighborhood  of  the 
wound,  as  they  might  bruise  the  bowel 
it  it  requires  to  be  drawn  out  in  the 
process  of  separating  the  appendix.  Re- 
moving the  sponge  from  the  abdomen, 
the  appendix  is  found  in  connection 
with  one  of  the  longitudinal  bands  pass- 
ing downward,  inward,  or  backward, 
and,  with  care,  it  is  separated.  At 
times  it  is  so  adherent  that  it  is  wiser 
to  leave  it  alone  and  trust  to  the  eiTect 
of  the  exploratory  incision.  Having 
separated  the  appendix  and  tied  its 
mesentery,  it  is  removed. 


The  after-treatment  of  patients  who 
have  had  this  operation  performed  is 
the  same  as  is  used  in  other  abdominal 
cases.  The  patient  is  to  be  gently  kept 
under  the  influence  of  morphine  for  two 
days,  and  only  soups  and  barley-water 
(starvation  diet)  are  to  be  given.  After 
the  bowels  have  been  moved  on  the 
sixth  day,  a  more  generous  diet  is  al- 
lowed, and  in  three  weeks  the  wound 
Avill  be  firndy  healed,  and  the  patient  be 
allowed  to  be  on  the  sofa  wearing  an 
elastic  bandage.  At  the  end  of  the 
fourth  week,  if  the  wound  has  been 
small,  walking  about  moderately  is  per- 
mitted, and  gradually  the  patient  re- 
sumes his  ordinary  work.  Generally 
great  improvenient  in  health  follows 
this  operation.  J.  C.  Renton  (Brit.  Med. 
Jour.,  May  25,  1901). 

"William  B.  Coley, 

New  York. 

ARGONIN.  —  Argonin  is  a  soluble 
silver-albumin  salt  prepared  by  mising 
sodium-casein  with  silver  nitrate  and 
adding  alcohol  until  precipitation  occurs. 

Argonin  appears  as  a  fine  white  pow- 
der, soluble  in  hot  water,  but  slightly  so 
in  cold. 

Physiological  Action. — When  applied 
locally  it  is  non-irritant  and  does  not 
coagulate  the  albumin  of  the  tissues. 
Like  argentamin,  it  is  regarded  as  pos- 
sessed of  considerable  antiseptic  value. 

When  administered  hypodermically 
the  symptoms  of  metallic  poisoning  ap- 
pear more  quickly  than  with  the  nitrate, 
which  may  be  due  to  the  peculiar  com- 
bination of  the  metal. 

Therapeutics. — It  may  be  used  where 
silver  nitrate  is  indicated;  but,  up  to 
present  writing,  definite  clinical  data 
are  wanting  to  establish  its  comparative 
value.  It  has  been  used  with  success 
in  gonorrhoea  and  tried  in  gonorrhoeal 
ophthalmia.  In  the  latter  affection  it 
did  not  seem  to  be  more  effective  than 
silver  nitrate.     The  price  of  the  drug  is 


496 


such,  however,  that  it  can  hardly  be  had 
generally. 

In  gonorrhoea  Jadassohn  recommended 
that  it  be  used  in  the  form  of  a  solution 
of  1  V2  parts  of  argonin  to  100  of  water. 
Of  this  solution  2  V2  drachms  are  in- 
jected five  times  a  day,  the  fluid  being 
retained  in  the  iirethra  for  five  minutes 
after  each  injection. 

Used  with  great  success  in  72  cases  of 
males  and  158  females.  The  urethritis  in 
both  sexes  rapidly  subsides  during  its 
use,  and  the  patient  is  more  speedily  re- 
stored by  this  treatment  than  by  any 
other  drug  extant,  as  the  gonococei  are 
destroyed  between  two  and  six  days. 
Bender  {Med.  Press  and  Circular,  Aug. 
12,  '96). 

Argonin  employed  in  ninety  cases  of 
gonorrhoea,  eighty  being  acute.  Used  in 
5-per-cent.  solution  by  the  patient  as  a 
hand  injection,  the  fluid  being  held  in 
the  urethra  five  minutes  after  each  in- 
jection.    Conclusions: — 

1.  It  is  absolutely  unirritating  and  can 
be  used  in  solutions  of  from  1  to  10  per 
cent. 

2.  In  the  great  majority  of  cases  it 
lessens  the  discharge  very  rapidly. 

3.  Its  use  is  generally  followed  in  a 
short  period  by  a  disappearance  of  the 
gonococei. 

4.  This  disappearance  of  the  gono- 
coccus  is  not  in  all  cases  permanent;  in 
other  vcords,  there  is  in  quite  a  large 
proportion  of  cases  a  distinct  tendency  to 
relapse,  with  reappearance  of  gonococei. 

5.  It  possesses  distinct  value  as  a  hand 
injection  in  the  stationary  period  of  the 
disease,  but  is  of  very  little  benefit  in 
the  mucous  stage,  or  stage  of  decline. 

6.  It  produced  no  results  in  the  treat- 
ment of  chronic  anterior  urethritis. 
Christian  (Ther.  Gaz.,  July  15,  '97). 

Personal  use  of  argonin  failed  to  show 
any  advantage  it  has  over  other  drugs. 
C.  F.  Marshall  (Treatment,  Jan.  27,  '98). 

In  gonorrhosal  ophthalmia  occurring  in 
the  adult  argonin  not  found  as  beneficial 
as  the  silver-nitrate  treatment  usually 
employed.  Kalish  (N.  Y.  Med.  Jour., 
Apr.  9,  '98). 

Thirteen  cases  of  purulent  ophthalmia 


in  infants  treated  with  argonin.  Three 
of  these  had  been  treated  in  this  way 
from  earliest  time  of  inflammation,  and 
had  been  cured  in  7  days.  In  the  other 
case  the  average  duration  had  been  13 
days.  A  carefully  prepared  3-per-cent. 
solution  of  argonin  had  been  used.  A 
minim  dropper  having  been  inserted  deep 
under  the  eyelid,  enough  of  the  solution 
sliould  be  instilled  to  thoroughly  irrigate 
the  eyelids  twice  and,  later,  once  in  the 
twenty-four  hours.  Between  these  ap- 
plications the  lids  were  kept  constantly 
clean  with  boric-acid  solution.  Fifteen 
grains  of  argonin  contain  as  much  silver 
as  a  grain  of  the  silver  nitrate.  No 
neutralizing  agent  was  required  after  its 
use.  Horace  Bigelow  (N.  Y.  Med.  Jour., 
Apr.  9,  '98). 

ARISTOI.  —  Aristol  (di-thymol-di-io- 
dide,  annidalin),  one  of  the  most  valu- 
able of  the  newer  antiseptics,  occurs  in 
crystals  of  a  light-reddish-brown  color, 
without  odor. 

It  is  insoluble  in  water,  slightly  solu- 
ble in  alcohol,  and  freely  soluble  in  ether 
and  fats.  It  contains  45.8  per  cent,  of 
iodine.  It  is  incompatible  with  acids, 
ammonia,  corrosive  sublimate,  metal  ox- 
ides, alkalies,  and  carbonates.  Heat  and 
light  have  a  deleterious  effect  upon  it. 

Dose  and  Physiological  Action.  — 
Aristol  is  almost  exclusively  used  as  an 
external  medicament,  but  may  be  given 
internally  in  maximum  daily  doses  of  6 
grains  in  cachets. 

It  may  be  used  externally  in  the  pow- 
dered form,  and  in  lO-per-cent.  solutions 
in  ether  or  oils,  and  in  the  form  of  an 
ointment  (10  per  cent.).  The  strength 
of  these  preparations  may  be  varied  from 
5  to  20  per  cent. 

Wax  and  lanolin  are  the  best  vehicles 
for  an  aristol  ointment.  If  glycerole  of 
starch  is  used  the  aristol  undergoes  par- 
tial decomposition  with  the  formation  of 
free  iodine.  With  vaselin  there  was  no 
decomposition,  but  the  ointment  was  not 
very    homogeneous.      With    benzoinated 


ARISTOL.    THERAPEUTICS. 


497 


lard  there  wa3  also  a  feeble  liberation  of 
iodine.     With  wax  and  with  lanolin  no 
iodine   was   set   free,   and   the   ointment 
was  perfectly  homogeneous.    These  sub- 
stances are,  therefore,  best  fitted  to  be 
used    as    vehicles    for   aristol    ointment. 
Fageardie  (Jour,  de  M6d.,  Dec.  20,  '96). 
Aristol   adheres   very  readily  to   the 
skin,  and,  therefore,  makes  an  excellent 
dusting-powder.     It   is  non-irritant   to 
the  unbroken  skin,  but  when  applied  to 
the  mucous  membrane  it  promotes  secre- 
tion.   It  is  not  absorbed  either  through 
raw  surfaces  or  mucous  membranes,  and 
is  therefore  free  from  toxic  effect. 

When  dusted  upon  wounds  or  ulcer- 
ated surfaces  when  abundant  secretion 
is  present,  it  serves  to  dry  up  the  secre- 
tions and  maintain  cleanliness  of  the 
dressings. 

If  the  surfaces  under  treatment  be 
rendered  aseptic  in  the  beginning  aristol 
will  preserve  asepsis. 

It  was  found  impossible  to  destroy 
cultures  of  the  various  cocci  and  bacilli 
by  the  application  of  aristol  alone.  If, 
however,  a  10-per-cent.  ethereal  solution 
was  used  and  the  ether  allowed  to  evap- 
orate, aristol  seemed  to  encapsule  the 
germs  and  thus  hinder  their  growth.  A. 
Neisser  (Berliner  klin.  Woch.,  May  12, 
'90). 

Report  of  twenty-two  cases  of  super- 
ficial wounds  in  which  aristol  appeared 
to  change  septic  into  aseptic  processes. 
Pollak  (Ther.  Monat.,  Dec,  '90) . 

Its  germicidal  action  is  very  limited, 

and  its  effects  on  bacteria  are  negative. 

Stern  (Fortschritte  der  Med.,  No.  19,  '91). 

It  not   only   diminishes  suppuration, 

but  favors  rapid  cicatrization. 

As  a  cicatrizant  and  resolvent,  aristol 
is  as  inoffensive  as  it  is  prompt  in  its 
action.     Seuvre    (Union  Med.   du   Nord- 
est,  Feb., '91). 
It  may  be  used  instead  of  iodoform, 
possessing    the    advantages    over    that 
agent  of  being  non-odorless  and  non- 
toxic.    When  given  internally  it  pro- 
duces no  untoward  symptoms. 

1- 


In  doses  of  37  V:  grains  per  kilo  weight 

of  guinea-pigs   and   dogs   there   was   no 

toxic  action  discernible.    Quinquaud  and 

Fournioux    (La    Tribune   Med.,   July   2, 

'90). 

It  seems  to  be  eliminated  by  the  urine 

as  an  alkaline  iodide  and,  probably,  also, 

as  thymol. 

Therapeutics. — Aristol  is,  perhaps,  the 
most  popular  of  the  newer  drugs  by 
reason  of  the  rapid  establishment  of  its 
therapeutic  uses  and  the  advantages  it 
possesses  over  others  of  its  class. 

Being  non-toxic  and  odorless,  it  en- 
joys the  distinction  of  displacing,  in  very 
many  conditions,  the  older  drug, — iodo- 
form. 

Simple  Ulcee.  —  Aristol  is  of  great 
value  when  the  ulcer  has  been  carefully 
scraped  and  disinfected,  by  actively 
stimulating  cicatrization. 

Three  rebellious  cases  in  which  aristol 
was  both  prompt  and  inoffensive.  Seuvre 
(Union  Med.  du  Nord-est,  Feb.,  '91). 

Report  of  forty  cases  in  which  aristol 
is  considered  of  great  value  in  the  cica- 
trization of  simple  ulcers,  being  more 
rapid  in  its  action  and  more  readily 
applied  than  iodoform.  Schmitt  (Revue 
Med.  de  I'Est,  May  1,  '91). 

Series   of   fifty   cases,   mostly   of   sup- 
purating wounds  and  varicose  ulcers,  but 
Including   some    cases   of   ulcerative   ad- 
enitis,   chilblains,    and    boils,    in    which 
aristol  ointment,  4  per  cent,  to  10  per 
cent.,  was  used,  applied  on  sterile  gauze. 
In  the  varicose  ulcers  the  results  were 
impeded  by  the  inability  of  the  patients 
to    take   necessary   rest.      In   ulcerating 
chilblains   the  action  of  aristol   was  es- 
pecially prompt.     Eriberto  Arevoli    (In- 
curabili,  '96). 
Burns.  —  Striking  results  have  been 
obtained  in  cases  of  burns  of  the  second 
and  third  degrees  after  other  remedies 
had  completely  failed.    Aristol  ointment 
may  be  used,  and  the  ease  with  which 
the  dressing  is  removed  and  the  early 
cicatrization    obtained    are    noticeable 
features  of  this  remedy. 
•32 


498 


APJSTOL.    THERAPEUTICS. 


Aristol  may  also  be  used  in  the  form 
of  powder  for  the  treatment  of  burns. 
The  surface  should  be  disinfected  with 
a  boric-acid  lotion,  and  after  opening  the 
vesicles  aristol  is  applied  and  the  whole 
is  covered  with  sterilized  cotton-wool, 
gutta-percha  paper,  and  a  bandage.  The 
application  of  aristol  powder  directly  to 
the  wound  at  the  beginning  hinders  the 
dressing  from  soaking  up  the  secretion; 
when  the  latter  has  diminished,  however, 
aristol  may  be  applied  either  alone  or  in 
a  10-per-cent.  ointment  with  olive-oil, 
vaselin,  and  lanolin. 

Case  of  excessive  suppuration  of  ttie 
legs,  knees,  and  soles  of  the  feet,  occur- 
ring in  an  engineer  as  the  result  of  scald- 
ing. An  ointment  of  aristol  changed 
the  appearance  in  twenty-four  hours,  and 
from  this  time  healing  continued  stead- 
ily and  rapidly,  an  almost  absolute  cure 
being  obtained  in  ten  weeks.  R.  Y. 
McCoy  (New  Eng.  Med.  Monthly,  Dec., 
'91). 

Aristol  is  recommended  as  of  value  in 

burns,  the  pain  being  almost   instantly 

relieved  and  healing  being  rapid.     Haas 

(Deutsche  med.  Woeh.,  p.  783,  '94). 

"Wounds. — Aristol  has  been  found  of 

marked  value  in  slight  wounds. 

Report  of  twenty-two  cases  of  super- 
ficial wounds  favorably  treated  with 
aristol.  Pollak  (Ther.  Monat.,  Dec,  '90). 
Aristol  film  recommended  for  the  pre- 
vention of  secondary  peritoneal  adhe- 
sions. When,  in  abdominal  surgery,  the 
surgeon  is  obliged  to  separate  extensive 
adhesions,  there  is  always  a  dread  that 
secondary  adhesions  will  form  shortly, 
and  that  the  patient  will  continue  to 
suffer  from  that  source  of  trouble.  The 
methods  of  smearing  the  surfaces  of  torn 
adhesions  with  oil,  or  filling  the  abdom- 
inal cavity  with  saline  solution,  are  quite 
uncertain  in  the  way  of  good  results. 
When  aristol  has  been  dusted  upon  a 
wound  it  shortly  forms  a  film  with  co- 
agulated lymph,  and  forms  a  mechanical 
obstacle  to  the  formation  of  secondary 
peritoneal  adhesions.  After  separating 
all  abnormally  adherent  peritoneal  sur- 
faces, and  waiting  until  oozing  has  al- 


most ceased,  aristol  is  sprinkled  over  the 
fresh  surfaces.    After  waiting  for  this  to 
be   held   by   lymph,   this   process   is  re- 
peated,  and,    having    formed   a    film    of 
aristol    and    lymph    over   the   region    of 
adhesions,  the  abdomen  is  closed.    Robert 
T.  Morris  (Amer.  Gyn.  Jour.,  Oct.,  '91). 
Number  of  eases  of  lacerated  and  con- 
tused   wounds    about    the    head    which 
healed  favorably  and  with  great  rapidity. 
Arevoli    (Incurabili,  '96). 
Skin  Diseases.  —  Aristol  has  shown 
itself  efficient  in  several  forms  of  skin 
disease.    In  lupus  it  produces  no  effect 
until  the  ulcerative  stage  is  reached,  be- 
cause of  the  fact  that  it  has  no  action 
upon   the   unbroken   skin   and   cannot, 
therefore,  penetrate  to  the  seat  of  dis- 
ease. 

In  cases  of  lupus  aristol  was  found  to 
have  an  effect  only  when  the  nodules 
had  been  previously  curetted.  Neisser 
(Berliner  med.  Woch.,  May  12,  '91). 

Combined  with  curetting  aristol  healed 
a   severe  case   in   five-  weeks   and  it  re- 
mained  so   ten   years   afterward.     It  is 
thought  that  the  drug  has  a  specific  ac- 
tion upon  the  tubercle  bacillus.    Gevaert 
(La  Flandre  Med.,  Feb.  21,  '95). 
In  eczema  it  has  not  been  extensively 
tried,   but   the  results   obtained  would 
tend  to  indicate  that  aristol  is  of  value. 
Aristol  used  as  an  ointment   (10   per 
cent,  to  20  per  cent.)   in  the  treatment 
of  eight  cases  with  satisfactory  results. 
Weissblum    (Centralb.    f.    die   gesammte 
Therap.,  May,  '91). 
In  psoriasis  it  does  not  act  as  rapidly 
as  ehrysophanic  or  pyrogallic  acid,  but, 
being  always  harmless,  it  may  be  used 
with  greater  freedom  and  may  thus  prove 
more  efficient. 

Although  it  produced  good  results  in 
twelve  cases,  conclusion  that  aristol  is 
inferior  to  chrysarobin.  Stern  (Fort- 
schritte  der  Medicin,  No.  19,  '91). 

In  severe  cases  it  was  found  to  be  of 
little  or  no  value.  In  one  case  it  pro- 
duced symptoms  of  irritation  on  the 
fourth  day.  Weissblum  (Centralb.  f.  die- 
gesammte  Therap.,  May,  '91). 


AKISTOL.    THEEAPEUTICS. 


499 


Htpehidhosis  and  Beomideosis.  — ■ 
Used  as  a  dusting-powder  in  these  con- 
ditions satisfactory  results  often  follow. 
Aristol  is  regarded  cleanly  and  effica- 
cious in  hyperidrosis.     In  some  cases  it 
was  combined  with  iodol  in  equal  parts. 
Daniel    Lewis     (Gaillard's    Med.    Jodr., 
Aug.,  '91). 

Venereal  Disohdees.  — ■  In  many  of 
the  Tcnereal  diseases  marked  by  ulcera- 
tion aristol  is  of  undisputed  value.  The 
majority  of  observers  agree  that  the  virus 
should  be  removed  from  the  diseased 
areas  with  the  curette  before  application 
of  the  drug. 

It  is  useful  in  chancroids,  syphilitic 
ulceration,  and  chancre. 

Moist  condylomata  on  the  genitals  of 
six  syphilitic  women  almost  dried  up 
in  three  days  by  the  use  of  aristol 
dusted  on  their  surface.  Other  syphilitic 
growths  in  various  parts  of  the  body 
also  did  well  by  this  treatment.  Seifert 
(Wiener  med.  Woch.,  No.  13,  '90). 

Aristol  acted  best  in  ulcers  previously 
freed  from  the  venereal  virus  by  some 
caustic,  and  in  adenitis.  In  balanitis, 
balanoposthitis,  and  in  initial  gummata 
the  drug  produced  slight  effect,  although 
better  results  were  obtained  in  ulcerating 
gummata.  SegrS  (Bollettino  della  Poli- 
ambulanza  di  Milano,  Sept.,  Oct.,  '90). 

Aristol  tried  in  the  treatment  of  syph- 
ilitic ulcers  of  various  stages.  Found  of 
especial  value  in  gangrenous  ulcers  and 
in  ulcerating  gumma  of  the  penis  and 
of  the  tibiae.  In  the  typical  ulcers  of 
syphilis  it  did  very  little  good,  being 
inferior  to  iodol.  Salsotto  (Gazzetta 
Medica  di  Torino,  Oct.  5,  '90) . 

Extensive  trial  in  a  large  variety  of 
venereal  disorders,  employing  the  medic- 
ament either  as  powder,  in  ointment,  or 
in  collodion.  It  acted  promptly  after 
destruction  of  the  virulence  in  the  in- 
fected focus.  Aristol  found  superior  to 
iodoform.  Breda  (Eevista  Veneta  di 
Seienze  Mediche,  Nov.,  '90). 

Aristol,     locally     applied,     has     acted 
better  than  other  remedies.     Rosenheim 
(Memphis  Med.  Monthly,  Apr.,  '91). 
In  the  true  Hunterian  chancre  aristol 


acts  injuriously.    W.  C.  AVile  (New  Eng. 
Med.  Monthly,  July,  '91). 

In  soft  sores  and  gonorrhoea  aristol 
found  unreliable.  Likewise  useless  in 
lupus.  It  did  good  as  an  aid  after  the 
healing  was  started  by  means  of  scrap- 
ing; the  same  favorable  results  were 
noticed  in  other  ulcerative  processes. 
Stern  (Fortschritte  der  Medicin,  No.  19, 
•91). 

Diseases  of  the  Ete.  —  Aristol  has 
been  found  of  value  in  indolent  corneal 
ulcerations  with  suppurating  base.  The 
powder  is  thickly  applied  with  a  brush 
and  the  eye  kept  closed  for  a  little  time. 
In  two  days  the  base  of  the  ulcer  is  said 
to  become  clean.  It  is  also  of  value  in 
blepharitis. 

Valuable  in  inflammatory  diseases  of 
the  eye,  especially  when  it  is  required  to 
suppress  a  focus  of  suppuration  or  re- 
pair a  loss  of  substance,  as  in  ulcerous- 
or  suppurative  keratitis.  Antiseptic  and 
harmless.  Bourgeois  (Union  M6d.  du 
Nord-est,  Feb.,  '91). 

Its  effects  most  markedly  comprise 
follicular  inflammations  of  the  conjunc- 
tiva, phlyctenular  disease  of  the  cornea 
and  conjunctiva,  marginal  blepharitis, 
ulcers,  and  after  enucleation  of  the  eye- 
ball as  a  desiccant.  In  papillary  tra- 
choma the  drug  seems  only  to  aggravate 
the  symptoms.  Wallace  (Univ.  Med. 
Mag.,  May,  '91). 

Two  cases  of  keratitis  dendritica,  both 
of  which  were  unassociated  with  herpetic 
trouble,  and  were  apparently  much  bene- 
fited by  insufflations  of  aristol.  Morton 
(Annals  of  Oph.  and  Otol.,  Apr.,  '93). 

In  a  5-per-cent.  ointment  it  is  useful 
in  ulcerative  blepharitis,  being  prefer- 
able to  the  ointment  of  yellow  precipi- 
tate on  account  of  its  causing  less  irri- 
tation. This  ointment  has  given  good 
results  in  obstinate  recurring  hordeola 
when  rubbed  into  the  edges  of  the  lids 
at  night.  Heuse  (Ther.  Monat.,  Feb., 
'95). 

Useful,  after  failure  of  other  measures, 
in  clearing  base  of  corneal  ulcers;  useful 
as  5-per-cent.  salve  in  ulcerous  blepharitis 
and  obstinately  recurring  styes.  Heuse 
(Ther.  Monat.,  Feb.,  '95). 


500 


ARISTOL.     THERAPEUTICS. 


Diseases  of  the  Ear. — In  afEections 
of  the  organ  of  hearing  it  has  shown  it- 
self of  Yahie  when  suppiirative  processes 
were  present. 

Twenty  cases  of  suppurative  otitis  in 
whicli  aristol  proved  serviceable.  The 
cavity  was  first  thoroughly  cleansed  and 
insufflations  practiced.  Rohrer  (Wiener 
nied.  Presse,  No.  20,  '90). 

The  drug  acts  very  favorably  in  acute 
and  subacute  internal  otitis,  and  in  ex- 
ternal-ear inflammations.  Burkner  (Oc- 
cidental Med.  Times,  Oct.,  '91). 

Aristol  effected  a  complete  cure  in 
twenty-two  out  of  thirty-three  cases  of 
chronic  purulent  otitis,  by  means  of  in- 
sufflations. Krebs  (La  Semaine  Med., 
Aug.  22,  '94). 

Recommended  in  suppurating  bony 
cavities  and  in  otorrhoea  with  large  per- 
foration of  tympanitic  membrane.  In 
cases  of  otorrhcea  with  small  perfora- 
tions it  is  dangerous  from  the  liability 
to  block  up  the  perforation  and  cause 
accumulation  of  pus  in  the  middle  ear. 
Gevaert  (La  Flandre  Med.,  Feb.  21,  '95). 

Affections  of  the  Nose  and 
Throat.  —  Powdered  aristol  can  be 
blown  through  tlie  iinest  tubes  to  the 
remotest  parts,  and  it  firmly  adheres  to 
the  mucous  membranes.  Sneezing  or 
other  unpleasant  symptoms  are  not  pro- 
duced by  its  use.  It  increases  secretion, 
and  is  therefore  not  to  be  recommended 
in  the  treatment  of  acute  rhinitis  or  in 
other  disorders  in  which  there  is  much 
secretion.  In  all  forms  of  chronic  rhi- 
nitis in  which  the  secretions  are  dimin- 
ished or  absent,  the  treatment  by  aristol 
is  more  or  less  successful. 

Aristol  tried  in  II  eases  of  acute  rhini- 
tis, but  found  valueless.  In  9  cases  of 
rhinitis  sicca,  even  when  complicated  by 
pharyngitis  sicca,  the  results  were  good. 
In  3  cases  of  rhinitis  atrophicans  simplex, 
6  of  rhinitis  atrophica  fcetida,  2  cases  of 
specific  ozoena,  with  perforation  of  the 
septum  cartilaginum,  and  7  cases  of 
laryngitis,   the  results   were   also   favor- 


able.     Hughes    (Deutsche    med.    Woch., 
May  1,  '90). 

Aristol  is  a  more  or  less  useful  remedy 
in  the  treatment  of  nose  and  throat  dis- 
eases, especially  in  cases  of  ozsena.  In 
ozEena,  a  solution,  in  liquid  petroleum, 
in  the  proportion  of  40  grains  to  the 
ounce,  may  be  employed.  W.  C.  Phillips 
(N.  Y.  Med.  Jour.,  May  23,  '91). 

In  atrophic  rhinitis,  a  valuable  deodor- 
izer and   germicide,   possessing,   further- 
more,  the   property   of  being   somewhat 
stimulating  and  tending  to  increase  the 
active    watery    elements    of    the    abnor- 
mally inspissated  secretions.     Insufflated 
with  a  powder-blower,  after  thoroughly 
cleansing.      H.     C.    Braislin     (Brooklyn 
Med.  Jour.,  June,  '91). 
Gynecology.  —  Aristol   has  been 
found  serviceable  in  endometritis,  ero- 
sions, hyperplasia  cervicis,  parametritis, 
and  eczema  vulvffi.    No  unpleasant  symp- 
toms were  produced,  though  large  quan- 
tities were  used.     Iodine  could  not  be 
found  in  either  the  urine  or  the  saliva. 
In  chronic  endometritis  aristol  acts  as 
a  valuable  alterative,  dissolved  in  a  10- 
per-cent.    solution    of   albolene.      W.    B. 
Chase   (Brooklyn  Med.  Jour.,  Jan.,  '94). 
In    endometritis,   after   thorough   cau- 
terization of  the  diseased  membrane   or 
curetting,  the  value  of  aristol  in  powder 
by  insufflation  is  especially  to  be  recom- 
mended.     No    deleterious    eft'ects    from 
absorption   need   be   feared    and    perfect 
asepsis  is  assured.     Its  value  in  ulcera- 
tions  of  the   OS   and   lacei'ations   of  the 
vaginal   wall   is  self-evident.     G.   C.   M. 
Meier  (Times  and  Register,  Apr.  II,  '96). 

In  disorders  of  children  it  has  been 
recommended  by  Moncorvo,  who  used  it 
externally  in  more  than  one  hundred 
infantile  cases,  the  drug  being  carefully 
rubbed  up  in  vaselin  in  variable  pro- 
portions, and  who  gave  it  internally 
in  cachets  to  tuberculous  children,  in 
maximum  daily  doses  of  6  grains.  In 
all  these  cases  it  proved  a  perfect  sub- 
stitute for  iodoform,  over  which  it  has 
the  advantage,  at  least  for  internal  use, 
of  being  tasteless. 


ARSENIC.     PEEPARATIONS. 


501 


Phthisis. — In  this  disease  aristol  has 
been  found  more  or  less  valuable  when 
administered  hypodermieally.  It  re- 
duced the  night-sweats  and  congh,  and 
the  general  health  was  much  improved 
by  its  use,  but  it  does  not  seem  to  merit 
much  confidence. 

Subcutaneous  injections  of  aristol  in 
six  cases  of  phthisis,  using  a  solution  of 
1  per  cent,  in  mild  almond-oil,  in  doses 
of  15  minims.  The  injections  were  not 
toxic,  but  very  painful,  the  pain  some- 
times continuing  throughout  the  entire 
day.  They  did  not  favorably  influence 
the  tuberculous  process.  It  is  true  that 
in  three  out  of  the  six  eases  the  sweats 
were  notably  diminished,  tlie  cough  less 
severe,  and  the  expectoration  more 
watery;  but  the  results  were,  after  all, 
not  encouraging.  No  great  reaction  ob- 
served.    Ochs   (Ther.  Monat.,  Jan.,  '93). 

Aristol  was  employed  in  progressively- 
increasing  doses  up  to  24  grains  daily, 
and  in  increasing  concentration  up  to  15 
per  cent.,  in  tlie  treatment  of  various 
forms  of  tuberculosis,  with  satisfactory 
results  in  cases  not  too  far  advanced. 
Bernardinone  (Eiforma  Medica,  No.  260, 
'94). 

ARSENIC.  —  Arsenic  (As),  a  native 
metal,  appears  as  a  lustrous,  crystalline, 
brittle  mass,  of  a  steel-gray  color,  with- 
out odor  or  taste.  It  volatilizes  above 
100°  C.  Commercial  white  arsenic  is 
prepared  from  the  native  ore  by  a  proc- 
ess of  roasting  and  sublimation. 

White  arsenic  (arsenic,  acidum  ar- 
senosum,  arsenous  oxide  or  anhydride, 
arsenic  trioxide,  AsaOj),  when  pure,  is 
a  white,  amorphous  powder,  odorless  and 
tasteless.  It  is  soluble  in  30  parts  of  cold 
and  15  parts  of  boiling  water;  also  in 
hydrochloric  acid  and  glycerin.  When 
thrown  upon  a  heated  surface  a  garlicky 
odor  is  emitted  and  the  fumes  resulting 
from  volatilization  are  very  poisonous. 

Preparations  and  Dose. — Arsenic,  Voo 
to  Yj2  grain. 


Liquor  acidi  arsenosi  (1  per  cent.),  1 
to  10  minims. 

Liquor  potassii  arsenitis  (1  per  cent. 
— Fowler's  solution),  1  to  10  minims. 

Liquor  sodii  arsenitis  (1  per  cent. — 
Pearson's  solution),  1  to  10  minims. 

Liquor  arsenii  et  hydrargyri  iodidi 
(Donovan's  solution),  1  to  10  minims. 

Arsenii  iodidi,  ^/j.,  to  ^/g  grain. 

Arsenii  sulphidum,  ^/^o  to  Vs  grain. 

Sodii  arsenias,  V24  to  ^/j,  grain. 

Cupric  arsenite,  ^/^w  to  V2  grain. 

Subcutaneous  Uses.- — Liquor  potas- 
sii arsenitis,  1  to  4  minims. 

Liquor  sodii  arsenitis,  1  to  4  minims. 
Arsenic,  in  the  form  of  1  part  of  an- 
hydrous sodium  arseniate  to  100  parts 
of  water,  the  dose  being  about  twice  that 
of  Fowler's  solution,  recommended  for 
hypodermic  use.  H.  N.  Moyer  (Ther. 
Gaz.,  Jan.,  '91). 

Scheele's  green,  or  Paris  green,  is  an 
impure  arsenite  of  copper. 

Clemens's  solution — a  solution  of  the 
bromide  of  arsenic — is  prepared  by  boil- 
ing 57  ^/a  grains  each  of  arsenous  acid 
and  carbonate  of  potash  in  8  fluidounces 
of  distilled  water  and  allowing  the  solu- 
tion to  cool,  to  which  is  then  added 
sufficient  distilled  water  to  make  11  V2 
fluidoimces.  To  this  are  added  115 
grains  of  pure  bromine.  The  resulting 
solution  is  kept  for  four  weeks,  being 
freqtiently  shaken  during  the  first  week, 
or  until  it  remains  clear.  Dose,  1  to  5 
minims,  freely  diluted,  after  meals. 

Cacodylic  acid  (dimethyl-arsenic  kako- 
dylie  acid),  a  supposedly  non-toxic  and 
easily  absorbed  preparation  of  arsenic, 
is  obtained  from  cacodyl  and  mercurous 
oxide  in  the  presence  of  water  (AsO- 
[CHgJsOH).  It  occurs  in  large  perma- 
nent prisms,  slightly  sour  and  odorless; 
it  is  soluble  in  water  and  alcohol  and 
melts  at  200°  C. 

Soda  cacodylate,  a  substitute  for  ar- 
senic,   is    especially    valuable    in    cases 


503 


ARSENIC.     PHYSIOLOGICAL  ACTION. 


where  large  doses  of  arsenic  must  be . 
given.  It  is  absolutely  safe  even  in 
massive  doses,  being  non-toxie  in  com- 
parison with  other  arsenical  compounds. 
It  may  be  given  hypodermically  in  doses 
of  from  1  to  1  V2  grains  daily,  and,  by 
the  mouth  and  rectum,  6  grains  daily. 
C.  W.  Heitzman  (Med.  News,  Aug.  17, 
1901). 

When  administering  arsenic  the  pos- 
sibility of  intolerance  on  the  part  of  the 
patient  should  be  thought  of  and  the 
first  doses  should  be  small. 

A  patient  who,  after  taking  a  very 
small  quantity,  was  seized  with  a  severe 
attack  of  diarrhoea  and  a  generalized 
oedema.  He  stated  that  ten  years  pre- 
viously he  had  had  a  similar  attack  after 
simply  touching  arsenic.  All  symptoms 
disappeared  after  the  cessation  of  the 
drug.  H.  Nicholson  (London  Lancet, 
Feb.  II,  '93). 

Results  of  experiences  with  rectal  in- 
jections of  arsenic.  It  is  administered  in 
solution  containing  '/-o  grain  in  1  ^U 
drachms.  Three  injections  may  be  given 
daily.  This  treatment  may  be  continued 
for  months  without  having  to  be  inter- 
rupted in  consequence  of  gastric  intoler- 
ance. Should  any  rectal  irritation  be 
caused  the  addition  of  a  few  drops  of 
laudanum  will  obviate  it.  This  treat- 
ment highly  recommended  in  tuber- 
culosis, especially  in  the  early  stage;  in 
diabetes  mellitus,  and  in  exophthalmic 
goitre.  Renaut  (Les  Nouveaux  Remedes, 
Apr.  24,  '98). 

Physiological  Action.  —  If  moistened 
and  applied  to  the  skin  arsenic  acts  as 
an  irritant,  its  power  as  such,  however, 
depending  upon  the  concentration  of 
the  preparation.  The  action  upon  the 
mucous  membranes  is  identical. 

Arsenic  is  readily  absorbed,  and  must 
therefore  be  used  with  care. 

Subcutaneous  injection  may  be  fol- 
lowed by  pain,  swelling,  and  even  abscess 
and  gangrene. 

Subcutaneous  injections  do  not  pro- 
duce digestive  derangements,  but  they 
determine  local  accidents  in  spite  of  all 


aseptic  precautions.  Arsenical  solutions 
become  infected  with  molds,  etc.,  very 
readily,  and  cause  irritation  at  the  site 
of  inoculation,  pain,  inflammatory  infil- 
tration, and  sometimes  even  abscess  or 
gangrene.  Ziemssen's  method  of  using 
a  sterile  solution  of  arseniate  of  soda 
tried,  but  convinced  that  the  method  of 
subcutaneous  injection  will  not  be  borne 
by  a  patient  very  long.  Vinay  (Lyon 
Medical,  Apr.  12,  '96). 

When  administered  internally  and  in 
small  doses,  arsenic  stimulates  the  mu- 
cous membrane,  thereby  sharpening  the 
appetite,  but  no  other  perceptible  effects 
are  produced.  It  raises  the  tone  of  the 
nervous  and  circulatory  systems  and  in- 
creases the  power  of  endurance. 

By  combining  with  the  corpuscular 
elements  of  the  blood  these  bodies  are 
enriched;  consequently  the  general  nu- 
tritive forces  are  improved  and  the  char- 
acter of  the  tissues  altered. 

Symptoms  observed  during  an  epi- 
demic of  arsenical  poisoning  in  Man- 
chester. Sensory  disorders  seem  to 
have  been  out  of  all  proportion  to  the 
amount  of  beer  or  stout  consumed.  The 
most  obtrusive  phenomena  were:  1. 
Numbness  and  tingling,  which  came  on 
rapidly,  in  both  hands  and  feet.  In 
some  a  painful  sense  of  a  burning  char- 
acter in  the  soles  of  the  feet,  making 
walking  painful,  was  all  that  was  noted. 
2.  Pain,  often  most  acute  on  pressing 
the  soles  of  the  feet,  especially  at  the 
heel  and  ball  of  the  great  and  little  toes. 
In  nearly  all  cases  the  pain  on  moving 
the  joints  was  excessive,  and  especially 
so  on  pressing  the  muscles ;  this  latter 
symptom  was  also  noted  in  a  number  of 
cases  in  the  forearm  mviseles.  3.  Several 
of  the  patients  showed  a  flushed  appear- 
ance of  the  sole,  especiallj'  at  the  great 
toe  and  heel,  rarely  spreading  on  to  the 
dorsum  of  the  foot,  and  associated  with 
pain,  making  the  picture  of  erythrome- 
lalgia;  but  the  swelling,  which  when 
associated  with  pain  and  redness  is  de- 
scribed as  typical  of  erythromelalgia, 
was  seen  in  but  one  case.  4.  Objective 
impairment  of  sensation  was  absent.    5. 


ARSENIC.    PHYSIOLOGICAL  ACTION'. 


503 


The  knee-jerks  were  often  present  and 
at  times  unusually  brisk.  W.  B.  War- 
rington (Brit.  Med.  Jour.,  Jan.  5,  1901). 
Armand  Gautier  found  that  small 
quantities  of  arsenic  were  present  in 
the  thyroid  gland  and  other  cellular 
elements.  The  writer,  after  a  series  of 
experiments  on  animals,  confirms  this 
fact,  and  concludes  that  arsenic  is  a 
normal  element  of  the  living  cell,  and 
is  to  be  found  in  all  animals  and  in 
all  organs.  Gabriel  Bertrand  (Le  Bulle- 
tin Mgdical,  Feb.  4,  1903). 

When  taken  for  a  long  time  the  sys- 
tem becomes  habituated  to  its  efEectsj  so 
that  much  larger  doses  may  be  tolerated. 

The  Styrian  arsenic  eaters  take  as 
much  as  8  or  10  grains  at  once,  but  take 
no  fluid  immediately  thereafter,  so  that 
absorption  progresses  slowly  and  elim- 
ination by  the  kidneys  rapidly.  This 
tolerance  for  the  drug  is  undoubtedly 
due,  to  some  extent,  to  environment  and 
heredity,  for  imitators  of  the  Styrians 
sooner  or  later  suffer  from  its  toxic 
effects. 

Arsenic,  used  for  a  considerable  period, 
produces  a  tingling  and  numbness  of  the 
tips  of  the  fingers.     (Hutchinson.) 

Nutrition. — Arsenic,  in  doses  of  Vs 
to  V4  grain,  increases  the  elimination  of 
urea  and  phosphoric  acid  and  dimin- 
ishes the  elimination  of  chloride  of  so- 
dium. In  large  doses — that  is,  more 
than  V4  grain — it  diminishes  the  excre- 
tion of  urea  and  increases  the  excretion 
of  phosphoric  acid  and  chloride  of  so- 
dium. In  small  doses,  the  elimination 
of  uric  acid  being  augmented,  nutrition 
is  increased  because  the  chloride  of 
sodium,  the  stimulant  par  excellence  of 
nutrition  and  the  preservative  of  the  red 
corpuscles,  is  retained  in  the  organism 
in  larger  quantities  than  normal,  thus 
stimulating  nutrition,  in  spite  of  the 
loss  of  phosphoric  acid.  The  contrary 
is  the  case  when  large  doses  are  given, 


the  unfavorable  action  being  attribut- 
able, first,  to  the  destructive  effect  of  the 
drug  on  the  red  corpuscles,  then  to  its 
action  on  the  chloride  of  sodium,  and 
finally  to  its  action  on  the  phosphoric 
acid.     (Viratelle.) 

Large  doses  are  pronouncedly  irritant, 
even  causative  of  gastro-enteritis.  The 
sj'mptoms  of  such  doses  are  usually  slight 
burning  or  colicky  pains  in  the  epigas- 
trium, nausea,  diarrhoea,  and,  if  the  dose 
be  sufficiently  large,  vomiting,  purging, 
and  generalized  abdominal  pain. 

Close  observation  of  the  patient  will 
disclose  a  puf&ness  about  the  eyes,  par- 
ticularly in  the  early  mornings.  This 
may  increase  into  a  decided  oedema,  and 
later  may  lose  its  local  character  and 
become  general.  The  urine  may  or  may 
not  contain  albumin  and  casts. 

This  puffiness  about  the  eyes  should, 
in  the  majority  of  cases,  be  regarded  as 
the  physiological  limit  of  administration. 
Neevotts  Ststeji. — Therapeutic  doses 
stimulate,  while  large  or  toxic  doses 
depress  or  even  paralyze,  the  nervous 
mechanism.  The  sensory  apparatus  is 
usually  the  first  affected,  the  reflex  and 
motor  following  in  order.  The  reverse 
may  occur.  Authorities  agree  that  ar- 
senic acts  directly  upon  the  nerve-centres 
through  changes  in  the  cell-elements. 

Three  cases  of  arsenical  neuritis,  the 
third  being  especially  interesting  be- 
cause the  left  upper  extremity  only  was 
involved.  It  is  imcommon  to  see  in- 
volvement of  but  one  extremity,  and 
apparently  the  left  upper  extremity  has 
been  reported  but  once  as  being  involved 
alone.  A  study  of  the  literature 
clearly  demonstrates  that  arsenical 
neuritis  is  most  frequently  due  to  acute 
intoxication  with  arsenic.  Series  of  253 
cases,  of  which  136  were  due  to  acute 
poisoning.  The  condition  most  fre- 
quently involves  the  lower  extremities, 
and  the  peripheral  parts — viz.,  the  feet, 
the   hands,  and   the  lower   part   of  the 


504 


ARSENIC.    PHYSIOLOGICAL  ACTION. 


legs — are  the  favorite  seats.  AV.  Janow- 
ski  (Zeits.  f.  klin.  Med.,  Bd.  xlvi,  Nos. 
1  to  4,  1902). 

That  the  long-continued  use  of  arsenic 
affects  the  peripheral  nerves  is  certainly 
proved  by  the  presence  of  a  wide-spread 
multiple  neuritis  in  many  cases  of  chronic 
arsenical  poisoning. 

Case  of  a  girl,  aged  19,  who  took  by 
mistake  a  packet  of  arsenous  acid. 
Acute  symptoms  of  arsenical  intoxication 
lasted  three  days.  There  then  super- 
vened symptoms  of  toxic  polyneuritis, 
which  in  turn  disappeared.  Fifteen  days 
later  invalid  had  considerable  atrophy  of 
the  muscles  of  the  limbs  and  trunk, 
motor  paralysis,  and  very  pronounced 
cutaneous  and  muscular  hyperaesthesia. 
Treatment  consisted  of  hypodermic  in- 
jections of  strychnine,  massage,  hydro- 
therapy, electricity,  and  iodide  of  potas- 
sium, under  which  the  patient  gradually 
improved,  but  is  not  yet  well.  M.  Krever 
(Gaz.  Hebdom.  de  Med.  et  de  Chir.,  Sept. 
15,  '98). 

Tingling  of  the  fingers,  formications, 
headache,  giddiness,  and  muscular  trem- 
ors result  from  too  large  a  dose  of  arsenic, 
while  even  convulsions  may  precede  the 
paralysis  of  a  lethal  dose.  The  tendency 
to  give  arsenic  in  large  doses,  on  account 
of  its  great  value  in  certain  diseases,  is 
leading  to  the  publication  of  several  cases 
where  paralysis  has  ensued. 

Case  of  girl  suffering  from  chorea  who 
took  arsenic  in  15-minim  doses,  given 
three  times  a  day  for  31  days,  except  on 
6  of  those  daj'S.  The  chorea  Avas  speedily 
cured,  and  drug  stopped;  but  13  days 
after  its  cessation  she  began  to  suffer 
from  symptoms  which  ushered  in  periph- 
eral neuritis  and  almost  complete  paral- 
ysis of  all  extensor  muscles  below  the 
knees,  with  well-marked  reaction  of  de- 
generation, and  some  weakness  of  the 
extensor  muscles  of  the  forearms.  She 
had  arsenical  pigmentation  of  the  neck 
and  the  groins;  but  under  treatment 
by  rest,  massage,  and  electricity  she 
rapidly  recovered.  Colman  (Brit.  Med. 
Jour.,  Jan.  22,  '98). 


Arsenic  interferes  with  the  normal 
metabolism,  but  the  exact  nature  of  the 
chemical  changes  which  occur  is  not 
understood.  While  beneficial  in  very 
minute  doses,  in  sufficiently  large  quan- 
tities it  may  produce  inflammation  in 
any  part  of  the  body,  either  applied 
directly  or  through  the  circulation.  The 
stomach  may  be  irritated  by  direct  ac- 
tion, or  after  the  arsenic  is  absorbed  the 
stomach  may  become  the  seat  of  inflam- 
mation from  the  arsenic  in  the  circula- 
tion. The  arsenic  in  the  circulation 
reaches  all  tissues.  Almost  all  of  the 
symptoms  are  produced  by  the  action  of 
the  irritant  in  this  manner.  There  can 
be  but  little  or  no  doubt  that  the  cause 
of  the  recent  Manchester  epidemic  was 
due  to  arsenic,  because  there  wa.<!  an 
absence  of  any  other  sufficient  cause; 
sufficient  arsenic  was  discovered  to  pro- 
duce the  symptoms  of  poisoning;  and 
that  the  symptoms  were  identical  with 
those  produced  by  chronic  arsenic  taken 
in  other  ways.  T.  Lauder  Brunton 
(Lancet,  May  4,  1901). 

There  is  no  doubt  as  to  the  possi- 
bility for  evil  of  small  quantities  of 
arsenic  taken  daily  over  a  period  of 
time.  At  the  same  time,  there  is  no 
doubt  as  to  the  great  therapeutic  value 
of  arsenic  in  certain  morbid  conditions, 
and  as  to  the  justification  of  the  con- 
tinuance of  the  use  of  this  drug  in  these 
conditions.  Serious  chronic  arsenical 
poisoning  as  a  result  of  the  administra- 
tion of  this  drug  is  a  rarity.  The  tolera- 
tion of  arsenic  varies  in  different  in- 
dividuals and  under  different  conditions. 
Arsenic  is  of  signal  value  in  chorea, 
malaria,  asthma,  and  chronic  heart 
affections.  In  the  treatment  of  chlor- 
ansemia  it  is  often  combined  with  iron, 
but  there  is  no  evidence  to  show  that 
arsenic  acts  as  a  hsematinic  tonic. 
Ralph  Stockman  (Brit.  Med.  Jour.,  Oct. 
18,  1902). 
Skin.  —  The  long-continued  use  of 
arsenic  is  not  infrequently  followed  by 
changes  in  the  skin.  The  changes  may 
be  in  the  form  of  eruptions,  pigmenta- 
tion, etc. 

Case  of  brown  discoloration  of  the 
skin,   produced   by  long  use  of  arsenic, 


ARSENIC.    PHYSIOLOGICAL  ACTION. 


505 


in  a  boy^  10  years  of  age,  suffering  from 
persistent  fever,  followed  by  exophthal- 
mos and  thyroid  pulsation.  Tlie  patient 
took,  in  two  months,  1  ounce  of  the 
liquor  potassii  arsenitis  of  the  German 
Pharmacopoeia.  He  was  discharged  im- 
proved, but  in  fifteen  days  returned,  ex- 
hibiting a  yellowish  discoloration  of  the 
skin,  face,  and  trunk,  which  gradually 
deepened  into  brown.  Foerster  (Berliner 
klin.  AVoch.,  Dec.  8,  '90). 

Case  of  a  woman  of  40  years,  who  had 
taken  arsenic  for  more  than  a  year,  in 
whom  the  skin  became  deeply  pigmented, 
the  heels  cracked  and  sore,  and  the  palms 
and  soles  very  dry.  There  were  also 
numerous  large  black  freckles  on  the 
face.  Hutchinson  (Archives  of  Surg., 
vol.  V,  p.  364,  '94). 

Case  in  which  boils  followed  the  con- 
tinuous administration  of  the  liquor 
potassii  arsenitis  (FoM'ler's  solution)  for 
an  old  and  exceedingly  chronic  psoriasis. 
J.  Abbott  Cantrell  (Med.  Summary,  Mar., 
'96). 

Valuable  as  arsenic  is  as  a  medicine  in 
certain  ailments,  if  judiciously  used,  it 
occasions,  if  taken  even  in  small  doses 
for  a  length  of  time,  not  merely  a  dingi- 
ness,  but  a  positive  pigmentation,  of  the 
skin  generally.  On  the  palms  and  soles 
it  exerts  its  stimulant  action  on  the 
sweat-glands,  giving  rise  first  to  hyperi- 
drosis  of  these  regions,  then  to  the  for- 
mation of  warty  corns  around  the  sudor- 
iparous orifices,  and,  finally,  to  a  diffuse 
hyperkeratosis,  associated  with  burning 
sensations.  W.  Allan  Jamieson  (Edin- 
burgh Med.  Jour.,  Jan.,  '98). 

Case  of  arsenical  melanoderma  simu- 
lating Addison's  disease,  including  the 
other  symptoms  of  the  latter.  The  pro- 
gressive weakness  and  intestinal  troubles 
of  Addison's  disease  are  not,  as  a  rule, 
present  in  arsenical  melanoderma,  and, 
moreover,  in  the  latter  case  there  are 
associated  dryness  of  the  throat  and  con- 
junctivitis. The  pigmentation  due  to 
arsenic  does  not  often  affect  the  hands  or 
feet,  and  the  peculiar  speckled  appear- 
ance of  the  trunk  is  characteristic.  It  is 
noticeable  that,  whereas  in  most  eases 
a  protracted  course  of  arsenic  is  neces- 
sary to  produce  pigmentation,  in  certain 


predisposed  persons  a  few  very  large 
doses  will  produce  the  same  effect.  En- 
riquez  et  LerebouUet  (Gaz.  Hebdom.  de 
Med.  et  de  Cliir.,  July  6,  '99). 

Unusual  poisoning  symptoms  in  four 
cases  of  chorea  which  were  taking  ar- 
senic. Peripheral  neuritis  developed  in 
three  of  these  cases  without  the  usual 
premonitory  signs  of  gastric  and  intes- 
tinal irritability.  The  paralysis  affected 
the  lower  extremities,  and  came  on  grad- 
ually for  several  weeks  after  the  termina- 
tion of  the  patient's  stay  in  the  hospital. 
All  of  the  cases  recovered  after  pro- 
tracted convalescence.  If  6V3  grains  of 
arsenous  acid  be  given  during  three 
weeks,  such  peripheral  paralysis  may  de- 
velop owing  to  slow  elimination.  F.  C. 
Eailton  (Med.  Chronicle,  No.  2,  1900). 

In  snails  poisoned  with  arsenic  there 
was  a  general  dilatation  of  the  lymph- 
vessels,  increase  in  the  quantity  of  pig- 
ment, and  fatty  degeneration  of  the  pro- 
toplasm of  the  parenchjTnatous  cells 
without  any  symptoms  of  inflammation. 
Plants  were  also  poisoned,  and  it  was 
found  upon  analysis  that  they  absorbed 
very  little  of  the  poison.  Stich  (Mun- 
chener  med.  Wochenschrift,  Mar.  12, 
1901). 

Secbetions. — In  therapeutic  doses  it 
facilitates  respiration,  improves  the  cir- 
culation, and  increases  the  urinary,  sali- 
vary, biliary,  and  cutaneous  secretions. 
(Comby.) 

Elimination. — Arsenic  is  very  rapidly 
eliminated,  and  chiefly  by  the  kidneys. 
The  mucous  membranes  of  the  alimen- 
tary tract,  the  skin,  tears,  and  saliva  also 
assist  in  the  process. 

Administered  h3'podermically  to  the 
dog  in  such  doses  as  to  produce  acute 
poisoning,  arsenic  is  eliminated  by  the 
urine  almost  wholly  unchanged;  the 
elimination,  beginning  immediately  after 
the  injection,  is  greatest  during  the  first 
few  hours,  and  continues  for  three  or 
four  days  at  the  most.  Even  in  cases  in 
which  small  doses  are  given  daily  no 
traces   of  arsenites  are  discoverable  in 


506 


ARSENIC.    POISONING. 


the  urine;  in  cases  in  which  rather  large 
doses  are  given  daily  for  ten  or  twelve 
days  the  elimination  of  arsenites  goes 
on  for  a  somewhat  longer  time  than 
stated  above.    (Severi.) 

Healthy  urines  of  20  persons  in  Berlin 

examined    for    arsenic    with    completely 

negative  results.     Putnam,  in  America, 

found  traces  of  arsenic  in  20  per  cent,  of 

all  urines  tested;    this  is  to  show  that 

suppression  of  all  sources  of  adulteration 

and   contamination   by   arsenic   is  being 

satisfactorily    accomplished    in    Prussia. 

E.    Eichter    (Viertelj.    ger.    Med.,    Apr., 

'98). 

Administered  by  the  rectum,  arsenic 

is  thrown  out  by  the  mucous  membrane 

of  the  stomach  in  from  one-fourth  to 

one-half  hour  before  the  beginning  of 

the  elimination  by  the  kidneys.    (Kandi- 

doff.) 

Poisoning.  —  Acute  poisoning  is  evi- 
denced in  from  one-half  to  three-fourths 
of  an  hour  by  intense  burning  pain  in 
the  oesophagus  and  stomach,  rapidly  be- 
coming general  over  the  entire  abdomen; 
an  acrid,  metallic  taste;  violent  vomit- 
ing and  purging;  excessive  thirst;  sup- 
pression of  the  urine;  collapse;  convul- 
sions or  coma,  and  death  in  from  five  to 
twenty  hours. 

In  smaller  toxic  doses  the  symptoms 
are  less  pronounced  and  death  may  not 
occur  for  six  days. 

In  some  cases  profound  and  rapid  col- 
lapse without  pain  has  occurred;  in 
others  rapidly  developing  coma,  which 
may  be  mistaken  for  cholera.  Absence 
of  epidemic  and  history  should  eliminate 
the  latter. 

Arsenical  poisoning  in  children  attend- 
ing a  Christmas  party.  Symptoms  finally 
traced  to  the  burning  of  candles  which 
were  found  to  contain  Scheele's  green. 
(Med.  Eecord,  Mar.  30,  '89.) 

As  illustrated  by  the  Eobinson  family 
(in  which,  with  criminal  intent,  eight 
persons  were  poisoned  with  arsenic  in 
five  years)    it  is  impossible  to  tell  from 


the  symptoms  that  we  are  dealing  with 
a  case  of  arsenical  poisoning.  Certainty 
can  only  be  reached  by  a  chemical  ex- 
amination, or  proof  that  the  poison  has 
been  taken  into  the  system.  A.  F.  Holt 
(Boston  Med.  and  Surg.  Jour.,  Aug.  1, 
'89). 

Differential  diagnosis  between  arsenical 
poisoning  and  ptomaine  poisoning.  In 
both  conditions  the  character  of  the 
main  signs  is  the  same.  The  chief 
points  of  difference  are  that,  in  arsenic 
poisoning,  swallowing  may  be  difficult  on 
account  of  pain  in  the  throat;  in 
ptomaine  poisoning  on  account  of  paral- 
ysis of  the  constrictors  of  the  pharynx; 
in  ptomaine  poisoning  the  pupils  are 
usually  dilated,  and  the  muscular  pros- 
tration is  extreme,  amounting,  in  fact, 
to  paralysis.  Harrington  (Boston  Med. 
and  Surg.  Jour.,  Dec.  14,  '99). 

Many  cases  of  poisoning  have  been 
reported  as  a  result  of  external  appli- 
cation of  arsenic.  Introduction  into  the 
vagina  has  also  caused  death. 

Death  of  a  woman,  aged  53,  suffering 
with  cancer,  probably  from  the  applica- 
tion of  an  arsenical  plaster  to  the  breast. 
A  positive  case  also  recorded  as  occur- 
ring in  1883,  where  an  arsenical  plaster 
applied  to  a  tumor  caused  death.  C.  A. 
Cameron  (Brit.  Med.  Jour.,  July  26,  '90). 
Case  of  a  servant-girl,  25  years  old, 
who  committed  suicide  by  introducing 
white  arsenic  into  her  vagina.  The 
quantity  found  in  the  vaginal  canal 
amounted  to  nearly  6  grains;  in  the  in- 
ternal organs  V2  grain  of  arsenous  acid 
was  found.  Deceased  had  not  been  preg- 
nant. Haberda  (Wiener  klin.  Woch., 
No.  9,  Mar.  4,  '97). 

Although  the  system  can  easily  toler- 
ate gradually  increased  doses,  chronic 
arsenical  poisoning  is  not  of  infrequent 
occurrence  from  various  causes. 

Eecord  of  twenty-six  cases  of  chronic 
arsenical  poisoning  from  wall-paper.  Es- 
pecial attention  called  to  the  frequent 
occurrence  of  albuminuria.  James  Put- 
nam (Boston  Med.  and  Surg.  Jour.,  Mar. 
7,  '89). 

A  ease  of  poisoning  from  the  use  of 
an  arsenical  ointment  given  in  the  treat- 


ARSENIC.     POISONING.     TREATMENT. 


507 


ment  of  skin  disease.  During  four 
montlis  the  entii'e  amount  used  was  cal- 
culated to  be  equivalent  to  20  grains  of 
arsenious  acid.  R.  Krehl  (Arcliiv  f.  klin. 
Mediein,  vol.  iv.  No.  44,  '89). 

Six  cases  in  which  jaundice  was  pres- 
ent in  chronic  arsenical  poisoning.  A. 
Freer   (Brit.  Med.  Jour.,  Aug.  1,  '89). 

Case  of  a  patient,  aged  50,  who  had 
for  about  twenty  years  taken  V:  to  Va 
grain  of  arseniate  of  sodium  daily.  On 
increasing  the  dose  he  suffered  from  all 
the  symptoms  of  arsenical  poisoning. 
Inclination  to  think  that  the  symptoms 
were  due  to  a  peripheral  neuritis. 
Mathieu  (Le  Prog.  Med.,  vol.  i,  p.  244, 
'94). 

Arsenic  enters  largely  into  the  com- 
position of  various  articles  of  domestic 
economy  and  was  at  one  time  a  constant 
constituent  of  colored  wall-paper.  It  is 
often  added  to  common  candles  to  give 
them  a  wax-like  appearance.  It  is  used 
ill  the  binding  of  books,  and  the  dust 
which  collects  on  the  top  of  the  book- 
cases in  libraries  often  contains  consid- 
erable quantities  of  arsenic.  It  is  a  fre- 
quent constituent  of  the  outside  wrapper 
in  which  cigarettes  and  tobaccos  are  sold, 
and  it  is  also  used  in  coloring  carpets, 
advertisement  cards,  playing-cards,  In- 
dia-rubber balls,  dolls  and  children's 
toys,  artificial  flowers,  sweets,  hat-linings, 
gloves,  and  a  number  of  other  substances. 
There  is  an  impression  that  arsenic  is  a 
common  ingredient  of  the  "face  pow- 
ders"; although  zinc,  bismuth,  and  lead 
are  often  present,  arsenic  is  uniformly 
absent.     (Murrell.) 

A  preliminary  report  as  to  the  pres- 
ence of  arsenic  in  cigarette-wrappers: 
Out  of  seventeen  series  of  different  kinds 
of  cigarettes  and  tobacco,  arsenic  was 
present  in  the  labels  of  six,  or  more  than 
a  third.  The  arsenic  in  these  cases  was 
present  in  such  large  quantities  that  no 
difficulty  was  experienced  in  demonstrat- 
ing the  fact.  Suggestion  that,  as  the 
inhalation  of  arsenous  acid,  even  in 
minute    quantities,    for    a    considerable 


time    produces    cough,    haemoptysis,    ex- 
pectoration, and  loss  of  flesh,  which  are 
readily  mistaken  for  phthisis,  the  advan- 
tage  of  accurate   knowledge   concerning 
this  subject  is  most  apparent.     Murrell 
and  Hale  (Brit.  Med.  Jour.,  July  11,  '96). 
Treatment    of    Poisoning.  —  For    the 
acute  form  the  most  effective  antidote  is 
the  hydrated  oxide  of  iron  and  magnesia, 
prepared  by  precipitating  the  solution  of 
tersulphate  of  iron  by  magnesia.  Twenty 
grains  of  the  antidote  should  be  given 
for  every  grain  of  arsenic  ingested. 

A  solution  of  dialyzed  iron,  the  tinct- 
ure of  the  chloride,  Monsell's  solution, 
or  any  of  the  sesquialteral  preparations 
may  be  substituted  in  emergencies. 

An  emetic  should  be  given,  or  the 
stomach  emptied  by  the  pump,  and,  if 
the  bowels  have  not  moved,  a  dose  of 
castor-oil  or  Epsom  salts  should  be  ad- 
ministered. 

Demulcent  drinks  should  be  freely 
given,  together  with  stimulation,  ex- 
ternal dry  heat,  and  friction.  Other 
treatment  must  be  governed  by  the 
symptoms  as  they  arise.  Opium  for  pain, 
and  large  draughts  of  water  if  there  be 
a  tendency  to  suppression  of  urine,  are 
also  indicated. 

In  chronic  arsenical  poisoning  the 
patient  should  naturally  be  removed 
from  contact  with  the  offending  agent 
and  treated  symptomatically.  Potassium 
iodide  is  the  most  effective  agent  in  such 
cases. 

The  pathological  changes  are  those  re- 
sulting from  violent  irritation.  Hyper- 
semia,  infiltration  oedema,  ecchymoses, 
and  membranous  exudation,  which  is  of 
a  pale-yellow  color  and  adherent  to  the 
swelled  mucosa,  are  all  to  be  noted.  In 
the  case  of  poisoning  through  the  intro- 
duction of  arsenic  into  the  vagina  there 
was  acute  inflammation,  with  false  mem- 
brane on  the  labia  minora  and  incipient 
sloughing  of  the  rectal  mucosa  over  the 


508 


ARSENIC.    THERAPEUTICS. 


recto-vaginal  septum.  The  labia  majoia 
were  also  very  oedematous. 

Therapeutics.  —  Arsenic  is  well  borne 
by  children;  bi\t  in  too  large  doses,  too 
long  continued,  it  causes  anorexia,  grave 
disturbances  of  digestion,  vomiting,  diar- 
rhoea, cutaneous  eruptions,  pallor,  and 
auEEmia.  Although  rarely  prescribed 
before  the  age  of  two  or  three  years,  re- 
course may  be  had  to  it  even  in  a  nurs- 
ling who  has  asthma,  pulmonary  tuber- 
culosis, leuksemia,  or  pseudoleukemia, 
or  chronic  malarial  affections,  heredi- 
tary or  acquired.  In  older  children  the 
indications  for  arsenic  become  more  nu- 
merous, but,  as  is  the  case  with  adults, 
arsenic  should  not  be  given  in  cases  with 
nephritis,  albuminuria,  gastro-intestinal 
dyspepsia  (with  diarrhcea,  vomiting,  etc.), 
or  in  the  acute  infectious  diseases. 

The  drug  accumulating  in  certain  vis- 
cera, the  administration  should  be  sus- 
pended for  eight  to  ten  days  after  fifteen 
days'  use.  Arsenic  being  very  irritating 
to  mucous  membranes,  it  should  be  given 
well  diluted.    (Comby.) 

Blood  Disoedees. — After  the  prep- 
arations of  iron,  arsenic  is  the  best 
remedy  we  have  in  the  treatment  of 
uncomplicated  anaemia.  In  pernicious 
ansemia  it  is  far  superior  to  iron;  in 
fact,  the  latter  remedy  sometimes  proves 
hurtful.  In  leuksemia  and  pseudoleu- 
kemia it  is  also  very  beneficial. 

Report  of  21  cases  of  anaemia  success- 
fully treated  with  arsenic:  Ten  recov- 
ered without  recurrence;  5  had  one  re- 
lapse; 4  two  relapses;  and  2  six  relapses. 
Of  these  recurrent  cases,  4  were  well  at 
the  time  of  report  and  7  died  during 
the  relapse,  generally  from  some  compli- 
cation. In  leuksemia  and  pseudoleu- 
koemia  the  results  were  not  so  satisfac- 
tory. Arsenic  is  as  much  of  a  specific 
in  pernicious  antemia  as  mercury  is  in 
syphilis.  Warfvinge  (Trans.  Eleventh 
Inter.  Med.  Cong.,  '94). 


Kew  organic  arsenical  compound 
which  obviates  the  unpleasant  effects  of 
the  cacodylates  and  yet  secures  equal 
benefit.  Such  a  substance  has  been 
found  in  arrhenal,  or  disodic  methyl 
arsenite.  This  drug  can  be  given  by  the 
mouth  or  subcutaneously,  it  has  no 
odor,  and  is  almost  tasteless.  It  does 
not  provoke  nausea,  eructations,  garlic 
odor  of  the  breath,  dyspepsia,  or  renal 
trouble  (albuminuria),  and  is  thus  su- 
perior to  the  cacodylates.  The  author 
has  extensively  used  it  with  successive 
paludism,  tuberculosis,  chorea,  bronchial 
asthma,  leuksemia,  and  adenopathies,  as 
well  as  in  skin  affections,  for  which 
arsenic  has  hitherto  been  prescribed. 
The  dose  for  an  adult  shoiild  not  ex- 
ceed 15  centigrammes  (or,  in  rare  in- 
stances, 20  centigrammes)  per  day.  A 
dose  of  2  to  5  centigrammes  thrice  daily 
gives  the  maximum  action,  especially  in 
tuberculosis.  Gautier  has  also  given  it 
with  success  in  hepatic  congestion  and 
cirrhosis,  and  in  cases  of  intestinal  and 
pulmonary  hsemcrrhage,  but  in  the  lat- 
ter cases  the  dose  should  be  small.  The 
method  of  administration  should  gen- 
erally be  to  give  the  drug  for  five  to 
seven  days  continuously;  then  it  should 
be  stopped  for  an  equal  interval,  and 
resumed  as  before.  Gautier  (Comptes- 
rendus  de  I'Acad.  de  Med.,  Feb.  25,  1902). 

Chobea. — In  this  disease  arsenic  has 
earned  a  well-deserved  reputation;  but 
the  drug  must  be  rapidly  pushed  to  the 
point  of  tolerance.  Then  the  doses  are 
gradually  decreased,  so  that  at  the  end 
of  ten  to  fifteen  days  the  child  is  satu- 
rated with  arsenous  acid  and  frequently 
cured  thereby. 

Experience  has  confirmed  the  value  of 
arsenic  as  a  specific  in  chorea.  It  should 
be  rapidly  pushed,  increasing  the  amount 
by  3  minims  per  dose,  t.  d.,  every  five 
days,  until  a  child  of  ten  years  is  taking 
35  minims,  t.  d.,  or  until  vomiting  is 
produced.  In  chronic  cases  arsenic  in 
large  doses  rarely  fails  to  cure  when  the 
drug  in  small  amounts  has  proved  use- 
less. It  is  also  serviceable  in  the  grave 
chorea  of  pregnant  women.  J.  Sawyer 
(Birmingham  Med.  RevieAV,  Jan.,  '88). 


ARSENIC.    THERAPEUTICS. 


509 


When  arsenic  is  badly  borne  by  the 
stomach  it  may  be  administered  hypo- 
dermically.  For  this  purpose  Fowler's 
solution  should  be  regarded  as  ineligible 
because  of  its  irritant  properties. 

The  local  irritation  following  the 
hj'podermic  injection  of  Fowler's  solu- 
tion is  due  to  a  small  quantity  of  free 
arsenous  acid  in  this  preparation.  It 
may  be  avoided  by  using  a  pure,  anhy- 
drous solution  of  arsenate  of  sodium, 
which  was  found  more  beneficial  than 
any  other  remedy  in  twenty-eight  cases 
of  chorea.  H.  N.  Meyer  (Jour.  Amer. 
Med.  Assoc,  Oct.  7,  '93). 

Large  doses  of  arsenic  have  a  beneficial 
influence  in  subduing  the  movements,  and 
this  is  best  seen  after  the  movements 
have  existed  for  some  time, — weeks  or 
months, — that  is,  when  a  cure  seems  al- 
most hopeless.  The  drug  should  be  given 
after  food,  and  the  little  patient  should 
lie  down  for  half  an  hour  afterward  in 
order  to  avoid  nausea  and  vomiting. 
Walker  Overend   (Lancet,  July  31,  '97). 

Infantile  Diaehhcea,  Cholera  In- 
fantum, ETC.  • —  Arsenite  of  copper  has 
proved  of  great  yalue  in  the  treatment 
of  summer  complaint  of  children,  es- 
pecially in  infantile  diarrhoeas  and  in 
dysentery.  After  administering  calomel 
in  minute  doses,  a  solution  of  6  to  8 
tablets  of  Vioo  grain  each,  in  half  a 
glassful  of  water,  is  given  in  teaspoonful 
doses  every  fifteen  minutes  until  six  or 
seven  doses  are  taken,  when  a  teaspoon- 
ful is  ordered  after  each  operation  of  the 
bowels.    (Owsley.) 

Arsenite  of  copper  does  most  good  in 
acute  forms  of  diarrhoea,  and  especially 
at  the  beginning  of  the  disease,  no  suc- 
cess being  obtained  in  a  case  that  has 
been  in  progress  for  twelve  hours.     S.  B. 
Overlock  (N.  Y.  Med.  Jour.,  Oct.  24,  '91). 
The   copper  salts   are  powerful   germ- 
destroyers,  but  should  not  be  given  in 
all   cases   of  diarrhcea,   the   best  results 
being   observed   in   acute    cases.     H.   B. 
Rue  (N.  Y.  Med.  Jour.,  Oct.  24,  '91). 
Ptjlmonaet  Disohders.  —  Asthma. 
—  Arsenic  sometimes  proves  useful  in 


asthma  when  administered  by  the  mouth, 
but  it  is  more  efEective  when  inhaled  in 
conjunction  with  hyoscyamus  and  stra- 
monium-leaves, in  cigarettes. 

Phthisis.  —  The  favorable  influence 
upon  nutrition  exerted  by  arsenic  renders 
it  useful  in  this  disease.  Fowler's  solu- 
tion, the  most  satisfactory  preparation, 
may  be  given  in  1-drop  doses  at  first,  the 
amount  being  gradually  increased  to  10 
drops.  It  sometimes  proves  efficacious  in 
arresting  night-sweats. 

Malaria. — In  the  malarial  cachexia 
arsenic  comes  second  in  value  to  the 
preparations  of  cinchona.  It  is  espe- 
cially valuable  when  the  cases  have  re- 
sisted quinine,  or  when  the  latter  is  not 
well  borne;  it  is  also  valuable  in  obsti- 
nate fevers  complicated  with  marked 
anjemia  and  large  spleen.  It  may  also 
be  used  as  an  adjuvant  to  the  antiperi- 
odic  alkaloids.    Large  doses  are  required. 

Arsenic  lends  itself  admirably  to  the 
hypodermic  method,  and  is  indicated 
when  the  salts  of  quinine  are  not  well 
tolerated,  and  arsenic,  on  being  resorted 
to,  is  in  time  not  well  borne  by  the 
stomach. 

Arsenic  is  a  valuable  prophylactic 
against  malaria.     (Downie.) 

Neuralgia   and   Gastealgia.  —  In 
these  disorders  arsenic  is  sometimes  of  . 
value,   especially  when   combined   with 
counter-irritation. 

Arsenic  is  one  of  the  best  agents  for 
the  cure  of  simple  gastralgia.  Recovery 
is  steadily  attained  in  ordinary  cases 
with  a  pill  of  '/;,  grain  of  arsenous  acid 
and  2  grains  of  extract  of  gentian. 
Sawyer  (Dietetic  Gaz.,  Jan.,  '88). 

Favorable  opinion  of  the  curative  effi- 
cacy of  arsenic  in  the  various  painful 
neuroses  included  under  the  name  "gas- 
tralgia" in  doses  of  'A,  grain  of  arsenous 
acid  made  into  a  pill  with  2  or  3  grains 
of  some  tonic  vegetable  extract,  such  as 
gentian,  three  times  daily  half-way  be- 
tween meals.     Scarcely  any  other  treat- 


510 


ARSENIC.    THERAPEUTICS. 


ment  is  needed  in  cases  of  moderate 
severity.  It  should  be  continued  for 
some  weeks.  In  severer  cases,  counter- 
irritation  to  the  epigastrium  added.  A 
varied  dietary  suits  gastralgie  patients 
far  better  than  a  restricted  one.  Trous- 
seau's maxim,  that  "we  should  know 
what  a  patient  does  eat  before  we  advise 
him  upon  what  he  may  feed,"  should 
be  followed.  James  Sawyer  (Lancet, 
July  4,  '96). 

Skin  Diseases. — Acute  affections  of 
the  skin — especially  the  acute  stage  of 
erythema^  eczema,  urticaria,  and  prurigo 
— are  not  favorably  influenced  by  ar- 
senic. On  the  other  hand,  it  represents 
the  most  effective  remedy  at  our  dis- 
posal in  the  treatment  of  chronic  skin 
disorders  when  employed  with  proper 
discrimination.  Fowler's  solution  is 
generally  considered  as  the  most  useful 
preparation.  From  3  to  5  drops  in  a 
half-glassful  of  pure  water  after  meals 
are  usually  well  borne.  The  dose  should 
be  slowly  increased  until  the  limit  of 
tolerance  is  reached. 

Psoriasis  promptly  yields,  especially  if 
the  treatment  is  begun  by  the  admin- 
istration of  a  saline   diuretic,   such   as 
acetate  or  bitartrate  of  potassium  (Rohe). 
Intravenous  injections  in  28   cases  of 
psoriasis,  in  25  of  Avhich  no  other  treat- 
ment was  adopted.    Ten  were  completely 
cured,  6  were  much  relieved,  and  9  re- 
ported as  under  treatment,  but  greatly 
improved.     The   commencing  dose   of   1 
milligramme  of  arsenous  acid  increased 
daily  by  1  milligramme  up  to  15  milli- 
grammes, the  maximum   dose,  which   is 
repeated   daily   till   the   eruption   disap- 
pears.    Herxheimer    (La   Semaine  M6d., 
clxii,  '97). 
Eczema  also  yields  to  the  influence  of 
arsenic,  but  only  when  it  is  employed 
in  the  chronic,  dry,  papular,  or  pustular 
stages  of  the  disease.    In  the  moist  form 
it  usually  proves  hurtful. 

Acne,  when  attended  by  any  degree 
of  active  inflammation,  is  aggravated  by 


arsenic;  but  in  the  small  papular  form 
and  that  occurring  during  the  menstrual 
period  it  frequently  proves  valuable, 
when  administered  in  small  doses. 

Pemphigus  is  favorably  influenced  by 
arsenic  when  the  latter  is  given  in  large 
doses.  Urticaria,  lichen,  and  furunculo- 
sis  are  also  greatly  benefited. 

Tumors. — Fowler's  solution  sometimes 
retards  the  progress  of  epithelioma.  It 
has  proved  curative  in  sarcoma  and  mel- 
anoma. 

Case  of  spindle-celled  sarcoma  at  head 
of  tibia  cured  by  internal  use  of  arsenic. 
Koenigsberg  (Deutsche  med.  Woch.,  Sept. 
23,  '94). 

Case  of  malignant  melanoma  cured  by 
Fowler's  solution  in  5-drop  doses,  t.  i.  d. 
Lassar  (Deutsche  med.  Zeitung,  No.  64, 
'94). 
In  cancer  the  local  application  of 
Marsden's  paste  (2  drachms  of  arsenous 
acid  and  1  drachm  of  mucilage  of  gwra 
acacia)  is  sometimes  effective.  A  layer 
of  paste  one  inch  in  diameter  being 
applied  over  the  growth,  a  piece  of  dry 
lint  is  applied  on  the  part,  overlapping 
the  paste  half  an  inch  all  around.  After 
ten  minutes  the  overlapping  linen  is 
carefitlly  cut  away  and  the  paste  is  al- 
lowed to  dry.  At  the  expiration  of  two 
or  three  days  bread  poultices  are  applied 
every  two  hours  until  the  redness  and 
swelling  present  subside.  A  true  line  of 
demarkation  appears,  the  skin  ulcerates, 
and  the  fissure  formed  gradually  extends 
until  the  cancerous  mass  comes  away. 

Case  of  a  woman,  aged  28,  undergoing 
treatment  for  cancer  of  the  breast,  after 
the  removal  of  the  epidermis  by  a  fly- 
blister.  Within  an  hour  she  began  to 
experience  the  physiological  effects  of 
arsenic:  objects  seen  double  or  treble 
and  marked  tinnitus  aurium.  Within 
six  hours  severe  vomiting  and  diarrhcea, 
which  continued  for  more  than  a  week. 
After  four  weeks  she  began  to  lose  power 
in  the  extremities  and  rapidly  became 
almost  completely  paralyzed.    There  was 


ARSENIC.    THERAPEUTICS. 


511 


pain  and  parsesthesia  in  the  extremities. 
She  began  to  improve,  although  inco- 
ordination of  extremities  well  marked. 
Eight  months  later  the  patient  was  able 
to  feed  and  dress  herself  and  walk,  but 
she  remained  an  invalid  a  long  time.  A. 
R.  Parson  (Dublin  Jour,  of  Med.  Science, 
Sept.,  '95). 

The  radical  cure  of  epithelioma  by 
arsenous  acid.  Arsenic  in  powder  prov- 
ing abortive,  a  solution  of  arsenous  acid 
in  equal  parts  of  rectified  spirit  and 
water,  of  the  strength  of  I  part  of  the 
acid  to  150  of  the  menstruum  employed. 
The  first  step  is  to  thoroughly  cleanse  the 
sore  by  vigorously  rubbing  or  scraping 
the  raw  surface,  a  moderate  quantity  of 
blood  being  allowed  to  flow.  The  surface 
of  the  ulcer  is  then  thoroughly  moistened 
with  the  solution,  shaken  up  before  using 
and  allowed  to  dry,  preferably  without 
dressing  of  any  kind.  A  scab  forms,  over 
which  the  solution  is  applied  daily.  The 
margins  of  the  scab  tend  to  separate 
from  the  subjacent  tissues;  the  treat- 
ment is  continued  until  the  scab  is  only 
retained  in  place  by  a  few  loose  adhe- 
sions. These  are  divided,  the  scab  re- 
moved, and  a  fresh  application  of  the 
arsenical  solution  is  made.  If  on  the 
following  day  the  resulting  scab  is  thin, 
of  a  light-yellow  color,  and  easily  de- 
tachable, it  indicates  that  the  tissues  no 
longer  comprise  any  trace  of  cancerous 
growth.  If,  on  the  other  hand,  a  dark- 
colored,  firm,  and  closely  adherent  scab 
again  forms,  the  whole  treatment  must 
be  repeated.  The  thicker  the  resulting 
scab,  the  more  energetic  should  be  the 
treatment:  that  is  to  say,  the  stronger 
should  be  the  solution,  the  strength  of 
which  may  then  be  increased  from  I  in 
150  to  1  in  100  or  even  to  1  in  80.  When 
the  desired  result  has  been  attained, 
there  remains  a  granulating  wound,  cov- 
ered with  a  delicate,  white  pellicle,  to  be 
dealt  with  on  general  principles.  Czerny 
and  Truneck  (Med.  Press,  May  26,  '97). 
Case  of  epithelioma,  in  which  recur- 
rence had  taken  place  after  surgical  in- 
terference, treated  with  painting  the 
growth  with  Czemy's  solution  of  arsenic, 
every  two  days.  Cure  took  place  in  short 
time.  Borde  (Ann.  de  Derm,  et  de  Syph., 
No.  2,  '98). 


Case  of  epithelioma  of  face  treated 
with  arsenous  acid,  which  was  applied  to 
the  surface  of  the  ulcer  and  left  exposed 
to  the  air,  after  the  method  of  Czerny. 
Growth  was  completely  destroyed  by 
third  month,  and  a  month  subsequent  to 
this  period  the  ulcer  had  cicatrized. 
Czerny's  method  consists  in  using  three 
solutions  of  arsenous  acid  in  equal  parts 
of  water  and  ethylic  alcohol.  The  first 
solution  is  of  the  strength  of  1  to  150, 
and  is  applied  directly  to  the  ulcerated 
area.  The  second  and  third  solutions  are 
stronger  and  are  applied  to  the  scab.  The 
ulcer  is  touched  with  a  solution  every 
day,  and,  if  the  pain  of  application  is 
severe,  hypodermic  injections  of  mor- 
phine are  given.  When  the  scab  drops 
off,  the  raw  surface  is  treated  as  is  an 
ordinary  wound.  Hermet  (Lancet,  Mar. 
26,  '98). 
"Warts  sometimes  yield  rapidly  under 
the  internal  use  of  arsenic  in  small  doses. 

The  internal  administration  of  the 
liquor  arsenicalis  in  the  treatment  of 
warts  recommended.  Report  of  a  num- 
ber of  cases  in  which  great  success  fol- 
lowed its  use,  and  without  any  external 
application  whatever.  Pullin  (Bristol 
Medico-Chir.  Jour.,  Dec,  '87). 

Internal  use  of  arsenic  recommended 
for  the  removal  of  warts  on  the  hands. 
The  commencing  dose  for  children  is  ^A 
drop  three  times  a  day,  the  quantity 
being  gradually  increased.  Paul  Miiller 
(London  Lancet,  July  4,  '91). 

Vomiting  of  Pregnancy.  —  In  this 
condition  arsenic  is  sometimes  of  value. 
The    following    formula   recommended 
in  the  vomiting  of  pregnancy: — ■ 
R  Aeidi  arseniosi, 

Ext.  ignatiae,  of  each,  'A  grain. 

Pulv.  ipecac, 

Ext.   cascara  sagradse,  of  each,   15 

grains. 
01.  gaultherise,  2  drops. 
M.  et  ft.  pil.  No.  20. 
Sig.:    One  pill  after  meals,  the  patient 
being   advised    to   take   dry    diet,    with 
liquids    principally    between    meals.      J. 
Aulde  (N.  Y.  Med.  Jour.,  '91). 

ARTHRITIS.    See  Joints,  Diseases 


512 


ASTHMA.    SYMPTOMS. 


ASTHMA  (from  the  Greek,  aad^ia; 
from,  do,  I  blow). 

Definition.  —  A  neurosis  characterized 
by  more  or  less  severe  paroxysmal  dysp- 
noea, due  to  spasmodic  narrowing  of  the 
bronchial  lumen,  alternating  with  spasm 
of  the  muscles  of  the  thorax. 

Symptoms. — In  the  typical  form  pre- 
monitory symptoms — such  as  uneasiness 
about  the  chest,  pallor,  or  a  feeling  of 
exultation,  due  to  unusual  good  health 
— occasionally  warn  the  patient  that  an 
attack  is  impending. 

Prodromata  of  asthma:  (1)  the  dysp- 
noeic  laugh;  (2)  repeated  sneezing;  (3) 
stridulous  laryngitis.  MoncorgS  (La 
Loire  Medicale,  Dec.  15,  '95). 

Suddenly,  in  the  early  hours  of  the 
morning  in  the  vast  majority  of  cases, 
great  constriction  of  the  chest  and  more 
or  less  marked  suffocation,  referred  to 
the  sternal  region,  are  experienced.  The 
dyspnoea,  in  bad  cases,  almost  reaches 
the  stage  of  apnoea;  the  respiration  is 
wheezing  in  the  milder  cases,  but  in  the 
others  it  is  scarcely  audible.  The  suf- 
fering of  such  cases  is  intense;  the 
patient  assumes  various  positions  calcu- 
lated to  assist  respiration;  there  is  prom- 
inence of  the  eyeballs,  distension  of  the 
superficial  vessels  of  the  neck,  blueness 
of  the  lips;  the  skin  is  clammy  and  cov- 
ered with  sweat,  etc. 

The  number  of  respirations  per  min- 
ute is  usually  reduced  and  the  expira- 
tions are  very  much  prolonged.  The 
chest  remains  expanded;  the  abdomen 
is  inordinately  protruded  through  the 
descent  of  the  diaphragm,  and  its  mus- 
cles are  tense  and  hard.  Percussion  gives 
rise  to  a  drum-like,  somewhat  high- 
pitched  note  over  the  areas  of  the  chest 
in  which  the  distension  of  the  alveoli 
by  the  imprisoned  air  is  most  marked. 
The  cardiac  and  hepatic  dullness  outline 


becomes  narrow  and  occasionally  sup- 
pressed by  the  overlying  inflated  lung. 

Auscultation  reveals  sibilous  rhonchi 
of  varying  pitch  and  intensity,  following 
the  rhythm  of  the  respiration.  They  re- 
semble the  chirping  of  birds  of  different 
varieties  and  size,  simultaneously  heard. 
This  is  accompanied  or  followed  by  mu- 
cous rales. 

The  variations  in  the  pitch  of  the 
notes  heard  are  due  to  the  variations  in 
the  diameter  of  lumina  left  in  the  bron- 
chi. Mucous  rales  are  present,  absent, 
coarse,  or  fine  according  to  the  natiire  of 
the  secretions  present.  Sometimes  noth- 
ing but  the  sibilous  rhonchi  are  heard. 

The  pulse  is  usually  slow  and  weak 
and  the  temperature  is  normal  in  the 
majority  of  cases,  rarely  reaching  100° 
F.    Frequently  it  descends  to  97  V2°  F. 

After  a  period  varying  from  half  an 
hour  to  several  hours  the  symptoms 
abate  and  end  by  a  more  or  less  profuse 
expectoration  of  viscid,  stringy  mucus, 
varying  in  opacity  according  to  the  se- 
verity of  the  attack. 

In .  a  small  proportion  of  eases  the 
fever,  cough,  and  purulent  nature  of 
the  sputum  tend  to  show  that  catarrhal 
bronchitis  is  present  as  a  complication. 
It  is  in  these  cases  that  emphysema  is 
most  likely  to  occur  later  on. 

The  expectorated  substance  is  found 
to  contain  minute  angular,  octahedral 
crystals,  visible  with  medium-power 
lenses,  and  recognized  as  the  Charcot- 
Leyden  crystals.  They  are  soluble  in 
warm  water,  the  alkalies,  and  the  mineral 
acids. 

[These  properties,  as  shown  by  Sal- 
kowski,  are  those  of  mucin.  The  asso- 
ciation is  further  supported  by  the  fact 
that  Loewy  found  the  same  crystals  in 
the  gelatinous  nasal  polypus,  although 
asthma  was  not  present.     Sajous.] 

The    sputum    also    contains    Cursch- 


ASTHMA.    COMPLICATIONS.      DIAGNOSIS. 


513 


mann's  spirals,  which  are  frequently 
sufficiently  large  to  be  recognized  with 
the  naked  eye.  They  consist  of  a  fine, 
closely-packed  layer  of  epithelial  cells 
arranged  in  a  spiral  form  around  a  longi- 
tudinal canal-like  film.  They  are  usu- 
ally found  in  the  thickest  portions  of  the 
sputum. 

[These  are  not  pathognomonic  of 
asthma,  being  also  found  in  the  diseases 
characterized  by  exudative  inflammation 
of  the  bronchioles,  as  shown  by  Vierordt. 
Sajous.] 

By  pressing  melted  wax  through  a  fine 
hole  the  spirals  of  Curschmann  are  imi- 
tated; they  are  produced  when  mucus  is 
pressed  through  the  contracted  bronchi- 
oles; they  must,  therefore,  be  considered 
as  a  product,  not  as  the  cause,  of  the 
bronchial  spasm.  Lisberg  (Hygieia,  '90). 
Spirals  of  Curschmann  are  not  limited 
to  any  particular  part  of  the  bronchi, 
but  are  absent  in  the  alveoli.  The  for- 
mation of  spirals  is  caused  by  the  whirl- 
ing of  the  air  during  long  paroxysms  of 
dyspnoea  or  violent  fits  of  coughing. 
Presence  of  fibrin  noted  in  the  sputum 
of  six  out  of  eight  cases.  Schmidt  (Med. 
Chronicle,  Nov.,  '92). 

Post-mortem  in  two  cases  showed  that 
the  majority  of  the  middle-sized  and 
small  bronchi  of  both  lungs  were  full 
of  the  most  perfect  spiral  coagula,  com- 
pletely blocking  the  lumen  of  the  smaller 
divisions.  Conclusions:  There  is  a  for- 
mation of  very  considerable  quantities  of 
an  exceptionally  tough  mucus.  As  this 
mucus  is  extruded  fi-om  the  cells,  but 
still  sticks  closely  to  them  on  account 
of  its  toughness,  it  is  swayed  backward 
and  forward  by  the  respiratory  currents, 
and  thus  exerts  on  the  neighboring  ele- 
ments a  stretching  influence  by  which 
they  are  not  only  mechanically  loosened 
from  their  connections,  but  also  finally 
attenuated  into  the  thread-like  forms 
described.  The  next  stage  in  the  process 
is  that  these  elongated  threads  get  more 
and  more  twisted  round  each  other,  and 
in  this  way  produce,  together  with  the 
mucus  present,  the  spirals.  Fraenkel 
(Deut.  med.  Woch.,  Mar.  19,  1900). 
Large  lymphoid  bodies  and  granules, 


the  eosinophile  cells  of  Ehrlich,  are  also 
found. 

[These   also   have   been   found   in   the 

contents  of  mucous  polypi.     Sajous.] 

The  urine  is  generally  very  copious, 

of  low  specific  gravity,  and  light  colored. 

It  is  usually  more  toxic  after  a  night 

attack. 

Essential,  or  nervous,  asthma  the  re- 
sult of  toxaemia,  occurs  more  frequently 
at  night,  because  sleep  is  in  itself  a  form 
of  toxaemia,  urine  passed  after  the  night 
being    usually    more    toxic    than    urine 
passed   after   the   day.      Huehard    (Kev. 
Gen.  de  Clin,  et  de  ThCr.  Jour,  des  Prat., 
Feb.  22,  '96). 
Complications.  —  The  most  important 
complication  of  asthma  is  emphysema. 
This  is  due  to  the  repeated  narrowing 
of  the  bronchi,  which,  assisted  by  the 
resulting  local  congestion,  becomes  more 
or  less  permanent  and  causes  dilatation 
of  the  alveoli. 

The  pulmonary  circulation  is  inter- 
fered with  and  dilatation  of  the  heart 
and  oedema  may  occur.  The  confor- 
mation of  the  patient's  frame  becomes 
changed,  owing  to  modified  action  of 
the  muscles  of  the  back  and  chest.  The 
sufferer  stoops  and  his  shoulders  become 
raised. 

Case    in    which    the    hands   and   arms 
were  symmetrically  enlarged  from  meta- 
carpo-phalangeal  joints  to  a   point  cor- 
responding to  the  middle  of  the  biceps 
muscle.     Under  iodide  of  potassium  and 
euphorbia   the    asthma   improved    some- 
what, but  the  enlargement  of  the  arms 
remained.     John  S.  Billings,  Jr.    (N.  Y. 
Med.  Jour.,  May  22,  '97). 
Differential  Diagnosis.  —  Attacks  re- 
sembling those  of  the  typical  form  may 
be  induced  by  pressure  on  the  trachea, 
aneurisms,    goitre    ("thymic    asthma"), 
foreign  bodies,  vertebral  disease,  gland- 
ular enlargement,  growths  of  the  larynx 
and  of  the  infraglottic  space. 

They  may  also  be  due  to  irregularity 
of  the  bronchial  circulation  through  car- 
33 


514 


ASTHMA.    DIAGNOSIS,    ETIOLOGY. 


diac  disorders,  tuberculosis,  bronchitis, 
or  narrowing  of  the  respiratory  area  by 
mediastinal  ttimors. 

Infraglottie  disorders,  growths,  and 
syphilis  especially  may  give  rise  to  a 
form  of  dyspnoea  simulating  that  of 
asthma.  Sajous  (Jour,  of  Laryn.,  Rhin., 
and  Otol.,  Sept.,  '95). 

The  great  majority  of  urgent  cases  of 
acute  stenosis  seen   occurred   low   down 
in  the  larynx,  either  in  region  of  true 
or  false  vocal  cords  or  below  the  glottis. 
Macintyre  (Jour,  of  Laryn.,  Sept.,  '95). 
Beonchitis. — In  children  asthma 
sometimes  assumes  the  character  of  cap- 
illary bronchitis.     In  all  forms  of  bron- 
chitis there  are  absence  of  periodicity, 
greater  amount  of  expectoration,  marked 
increase  in  number  of  respirations,  free 
chest-motion,  and  more  or  less  fever. 

Pneumonia. — In  this  disease  the  res- 
pirations are  greatly  increased  in  num- 
ber, and  there  is  panting,  besides  free 
chest-motion.  There  is  also  high  fever. 
Ceoup  and  Othee  Laetngeal  Dis- 
eases.— In  these  disorders  there  is  in- 
terference with  the  respiration:  inspira- 
tory instead  of  expiratory. 

Emphysema.  —  In  emphysema  the 
dyspnoea  is  continuous,  though  liable  to 
exacerbations. 

The    dyspnoea    of    emphysema    is    too 
often  attributed  to  asthma.    While  bron- 
chial   asthma    of    nasal    origin     occurs 
when  the  patient  is  at  rest,   and   espe- 
cially at  night,  the  dyspnoea  of  emphy- 
sema     mostly      appears      on      exertion. 
Schech  (Miinchener  med.  Woch.,  Aug.  18, 
'96). 
Heaet  Disease.  —  Dyspncea  usually 
follows  exercise  or  becomes  greatly  ag- 
gravated by  it  in  cardiac  disorders.    In 
advanced  cases  the  dyspnoea  is  continu- 
ous and  the  cardiac  lesions  are  easily 
recognized. 

Cardiac  asthma  occurs  suddenly  at 
night,  on  account  of  the  greater  tend- 
ency to  venous  stasis,  with  dyspnoea 
lasting  at  most  a  half-hour.    They  gen- 


erally reappear  night  after  night,  rarely 
twice  in  one  night.    They  occur  in  cases 
of  mitral  insuflficieney  with  loss  of  com- 
pensation, and  in  cases  of  advanced  ar- 
teriosclerosis   with    cardiac    dilatation, 
myocarditis,  and  renal  insufficiency.    M. 
Merklen   (Jour,  des  Praticiens,  Apr.  20, 
1901). 
Spasm  of  the  Diapheagm.- — In  this 
syniptom  there  are  sudden  spasmodic  ex- 
pulsive efforts,  frequently  accompanied 
by  hiccough. 

UEJ5MIA.  —  The  dyspnoea  occurring 
as  a  symptom  of  tirsemia  is  more  or  less 
continuous  and  accompanied  by  presence 
of  casts  in  the  tirine. 

Etiology.  • —  Heredity  shows  itself  in 
about  one-half  of  the  cases  when  three 
generations  are  included  in  the  compu- 
tation. 

The  influence  of  heredity  is  very  great; 
the  absence  of  asthma  in  the  family  his- 
tory greatly  increases  the  chances  of 
cure.  Dauchez  (Revue  Mensuelle  des 
Maladies  de  I'Enfance,  July,  '94). 

[If  collateral  diseases  dependent  upon 
an  arthritic  diathesis,  rheumatism,  gout, 
migraine,  etc.,  are  included  as  predis- 
posing factors,  as  taught  by  Trousseau, 
almost  every  case  Mill  be  found  to  be 
hereditary.     Sajotjs.] 

Asthma  presents  itself  before  the  age 
of  ten  years  in  one-fourth  of  the  cases, 
but  it  may  occur  at  any  period.  It  is 
more  frequent  among  males  than  among 
females.  The  wealthy  are  more  prone 
to  it  than  the  poor,  owing  to  dietetic 
errors  and  sedentary  habits,  the  latter 
cause  also  explaining  the  disease's  pre- 
dilection for  persons  deprived  of  phys- 
ical exercise,  such  as  clergymen,  lawyers, 
clerks,  etc. 

Atmospheric  influences  are  active 
factors  in  the  production  of  an  attack. 
Excessive  dryness,  such  as  that  of  over- 
heated or  insufhciently  ventilated  rooms, 
or,  on  the  contrary,  excessive  dampness 
may   bring   on   a   paroxysm.      Cases   in 


ASTHMA.     PATHOLOGY. 


515 


■which  a  rheumatic  diathesis  exists  are 
especially  sensitive  to  dampness. 

A  patient  living  on  one  side  of  the 
street  may  be  exempt  from  asthma,  while 
on  the  other  he  may  be  affected.  This 
may  be  due  to  the  fact  that  on  one  side 
he  lives  in  a  shady  room,  and  on  the 
other  in  a  sunny  one.  This  is  a  factor  of 
no  small  moment,  in  not  only  the  asth- 
matic, but  in  all  subacute  and  chronic 
bronchial  disorders.  J.  B.  Walker  (Re- 
port of  Amer.  Climat.  Soc,  Boston  Med. 
and   Surg.   Jour.,   Nov.    17,   '98). 

Asthma,  and  the  predisposition 
thereto,  depend  upon  four  causal  factors. 
Tendency  to  (1)  bronchial  spasm  (in- 
creased tone  of  the  bronchial  muscles), 
(2)  vasomotor  insufficiency  (decreased 
tone  of  vascular  musculature),  (3)  con- 
gestive liyperEsmia  of  the  respiratory 
mucous  membrane,  and  (4)  an  abnormal 
specific  secretion  from  the  same.  These 
four  factors  may  be  influenced  by  the 
peripheral  nervous  system,  the  con- 
stituents of  the  blood,  or  the  cerebrum, 
especially  the  cortex;  thus,  asthma  may 
be  peripherigenic,  hjematogenic,  or  psy- 
chogenic and  cerebral.  Sihle  (Wiener 
klin.  Woch.,  Jan.  22,  1903). 

Pathology.  —  Various  theories  have 
been  propounded  to  explain  the  dysp- 
noea,  but  the  prevailing  one  to-day  is 
that  it  is  due  primarily  to  spasm  of  the 
smaller  bronchi,  as  taught  by  Laennec, 
Biermer,  and  Williams,  and,  secondarily, 
by  spasm  of  the  muscles  of  the  thorax 
and  of  the  diaphragm,  which  are  unable 
to  cause  expulsion  of  the  air  imprisoned 
in  the  alveoli  on  account  of  the  restricted 
lumen  of  the  bronchi. 

[The  reduction  in  the  number  of  res- 
pirations would  tend  to  demonstrate  that 
the  resistance  to  the  egress  of  air  is  the 
main  cause  of  the  difficulty.  The  expired 
air  shows  an  increase  of  about  10  per 
cent,  in  carbonic  acid.  It  contains  little 
or  no  o.xygen  in  marked  cases,  the  blood 
having  absorbed  all  that  contained  in 
the  increased  residual  air.  This  com- 
pensatory effort  is  not  sufficient,  how- 
ever, to  satisfy  the  demands  of  the  sys- 


tem for  the  oxidation  of  the  tissues.  Im- 
perfect action  of  the  chest-walls  is  often 
due  to  momentary  paresis  of  their  mus- 
cular supply  induced  by  the  absorption 
of  CO;.    Sajous.] 

Primary  spasm  of  the  bronchial  mus- 
cles leads  to  a  subsequent  temporary 
paralysis,  by  which  the  increased  demand 
on  the  external  muscles  and  the  dyspnoea 
is  prolonged.  Spasms  of  the  bronchial 
muscles  render  the  muscles  of  expiration 
for  a  long  time  incapable  of  performing 
their  functions.  Cameron  (Brit.  Med. 
Jour.,  June  1,  '89). 

[The  theory  of  Salter — that  the  tem- 
porary contraction  of  the  bronchi  giving 
rise  to  the  dyspnoea  is  due  to  spasm  of 
the  circular  muscular  fibres  of  the  bron- 
chial tubes — is  losing  ground.     Sajous.] 

That  the  spasm  depends  upon  the  con- 
tractility of  the  circular  muscular  fibres 
of  the  bronchi  and  that  it  is  essentially 
spasmodic  in  character  is  the  only  view 
by  which  the  phenomena  of  the  disorder 
can  be  adequately  explained.  Wilson 
Fox  (Times  and  Register,  Apr.  2,  '92). 

The  spasm  of  the  bronchi,  by  impeding 
respiration,  produces  an  excess  of  CO,  in 
the  blood,  which  causes  abnormal  stimu- 
lation of  the  vagi.  This  action  and  re- 
action are  further  influenced  (1)  by  the 
reciprocal  effects  of  an  accumulation  of 
CO,  in  the  central  nervous  system  and 
a  retardation  of  the  circulation;  (2)  by 
the  rapid  production  of  CO,  in  the  or- 
ganism, in  consequence  of  the  powerful 
efforts  required  for  the  movements  of 
respiration.  Einthoven  (Nederlandsch 
Tyd.  voor  Genees.,  Oct.  7,  '93). 

Asthma,  in  accordance  with  the  view 
of  Germain  See,  must  be  considered  a 
bulbar  neurosis  consisting  in  an  excess- 
ive reflex  irritability  of  the  respiratory 
centre.  This  may  be  disturbed  in  its 
action  by  a  peripheral  irritation. 
Schmiegelow    (Chicago   Med.    Recorder). 

From  examination  with  the  aid  of  the 
fluoroscope  of  four  cases  of  asthma  dur- 
ing the  paroxysm,  it  was  possible  to  con- 
clude that  spasm  of  the  diaphragm  is  not 
the  only  cause  of  asthma.  H.  Schlesinger 
(Wiener  klin.  Woch.,  Apr.  14,  '98). 

The  diminished  lumina  of  the  tubes 
and  the  paresis  of  the  muscles  of  the 


616 


ASTHMA.     PATH01.0GY. 


ehest-walls  may  be  primarily  incited  by 
four  classes  of  factors: — 

1.  Eeflex  action,  the  starting-point  of 
which  may  be  located  in  the  naso-laryn- 
geal  tract,  the  ear,  the  month,  the  stom- 
ach, or  the  genital  organs,  etc. 

Nasal  disease  sometimes,  though  not 
necessarily,  constitutes  the  inciting  fac- 
tor; asthma  associated  with  nasal  polypi 
observed  in  22  per  cent,  of  pei'sonal  cases, 
and  with  chronic  rhinitis  in  8  per  cent. 
Schniiegelow  (Chicago  Med.  Recorder). 

Eighty  cases  shoeing  that  of  the  three 
elements  which  enter  into  the  causation 
of  asthma, — viz.,  a  neurotic  habit,  nasal 
disease,  and  atmospheric  conditions, — 
the  nasal  disorder  outweighs  all.  Bos- 
worth  (N.  Y.  Med.  Jour.,  Dee.  29,  '88). 

Distressing  cases  due  to  retroversion  of 
the  uterus  and  pressure  on  the  sacral 
nerves;  irritation  reflected  to  the  pneu- 
mogastric.  Further  attacks  prevented 
by  the  reposition  of  the  womb.  Car- 
■    penter  (Times  and  Register,  Jan.  4,  '90). 

Sexual  asthma;  eleven  males  and  five  . 
females.  In  almost  all  the  male  cases 
there  was  a  history  of  spermatorrhcea, 
together  with  self-abuse  and  impotence; 
attacks  follo\\ed  immediately  on  coitus 
or  other  sexual  excitement.  Peyer  (Ber- 
liner Klinik,  Mar.,  '90). 

Out  of  four  hundred  cases  the  superior 
turbinated,  and  sometimes  also  the  in- 
ferior turbinated,  found  so  swollen  as  to 
come  near  the  septum.  Torstenssohn 
(Edinburgh  Med.  Jour.,  Jan.,  '92). 

Case  in  which  the  sputum  possessed 
characteristic  features  of  asthma:  Ley- 
den's  crystals,  spirals,  and  sago-like  pel- 
lets, etc.  The  attacks  of  asthma  and  this 
characteristic  sputum  were  present  only 
during  the  menstrual  period.  The  pa- 
tient, aged  32  years,  was  in  every  other 
respect  healthy.  Katz  (Deutsche  med. 
Woch.,  Dec.  10,  '96). 

A  similar  case  in  which,  however,  the 
asthma  had  not  existed  previously.  The 
patient,  a  young  girl,  having  recovered, 
on  the  occurrence  of  the  menses  the 
asthma  had  again  developed,  and  the 
attacks  were  limited  to  the  menstrual 
period.  The  paroxysms  were  also  called 
forth  by  a  number  of  nervous  influences. 


especially  of  an  exciting  nature.  Von 
Leyden  (Med.  Press  and  Circular,  Dec. 
2,  '96). 

Two  cases  in  which  the  breathing  was 
characterized  by  unusual  slowness  and 
depth,  and  amounting  in  one  case  to  or- 
thopncea.  Cessation  of  the  asthmatic 
trouble  in  one  case  after  restoration  of 
a  retroflexed  uterus.  Strubing  (Zeit- 
schrift  f.  klin.  Med.,  B.  30,  H.  1,  2,  '97). 

Even  in  the  finer  bronchioles  of  the 
lower  animals  there  exists  a  powerful 
layer  of  circular  fibres  and  a  weak  layer 
of  longitudinal  fibres.  The  same  condi- 
tion exists  in  the  bronchioles  of  human 
beings,  particularly  in  portions  of  the 
lung  adjacent  to  the  inflammatory  foci. 
These  two  sets  of  muscle-fibres  thus  have 
an  antagonistic  action  in  cases  of  inflam- 
matory infiltration.  The  weaker  longi- 
tudinal fibres  are  more  aflTected  than  the 
horizontal  fibres,  and  are  unable  to 
oppose  their  contraction,  which  reduces 
the  diameter  of  the  bronchioles.  Au- 
frecht  (Deut.  Archiv  f.  klin.  Med.,  B. 
67,  H.  5,  6,  1900). 

2.  Irritation  of  the  bronchial  mucous 
membrane,  in  catarrhal  processes,  by 
dust  of  various  kinds,  metallic  (grinders' 
asthma)  or  pollen,  and  the  emanations 
of  various  plants,  fruits,  animals,  etc., 
in  beings  hypersensitive  to  their  action, 
or  of  irritating  chemicals:  sulphur, 
phosphorus,  etc.  (See  Hat  Fever,  In- 
dex.) 

3.  Irritability  of  the  sympathetic  sys- 
tem through  the  sudden  arrest  of  pe- 
ripheral disorders:  eczema,  urticaria, 
psoriasis. 

Frequent  occurrence  of  asthma  among 
persons  who,  in  their  youth,  suffered 
from  stubborn  cutaneous  eruptions.  Von 
Noorden  (Zeit.  f.  klin.  Med.,  B.  22,  '92). 

Case  of  urticarial  asthma  due  to 
mussel  poisoning,  indicating  the  rela- 
tionship between  urticarial  eruption  of 
the  skin  and  that  of  the  mucous  mem- 
brane, strongly  advocated  by  Andrew 
Clark  as  the  main  cause  of  asthma.  G. 
Martyn   (Brit.  Med.  Jour.,  June  8,  '95). 

Case  of  a  boy  whose  mother  was  an 
asthmatic  and  who  suffered  from  parox- 


ASTHMA.    PATHOLOGY. 


517 


ysms  of  asthma  and  eczema  which  were 
sometimes  concurrent,  sometimes  defi- 
nitely alternating,  sometimes  overlap- 
ping each  other,  the  patient  at  no  time 
being  quite  free  from  either.  Latterly 
he  has  had  intermissions  of  from  four  to 
five  weeks  in  the  asthmatic  fits,  but  the 
chronic  eczema  has  been  more  or  less 
constant.  Personal  belief  that  asthma 
may  be  due  to  some  sudden  vascular  en- 
gorgement or  erythematous  blush  of  the 
bronchial  mucosa.  As  against  the  ee- 
zematous  origin  of  these  attacks,  atten- 
tion called  to  the  non-evanescent  nature 
of  eczematous  eruptions.  Taylor  (N.  Y. 
Med.  Jour.,  Oct.  21,  '99). 

4.  Irritability  of  pneumogastric  nerve 
following  whooping-cough,  measles,  or 
infantile  bronchial  disorders,  or  through 
pressure  upon  it  of  enlarged  bronchial 


In  infants  the  bronchial  glands  are 
often  the  site  of  congestive  and  inflam- 
matory conditions  following  bronchitis, 
measles,  and  pertussis,  the  causes  of  the 
attacks  being  those  which  produce  con- 
gestion of  the  glands,  crying,  variation 
of  temperature,  chilling,  etc.  Joal  (Arch. 
Gen.  de  Med.,  Apr.,  '91). 

Thei'e  is  only  one  way  of  artificially 
producing  asthma,  and  that  is  to  divide 
the  left  vagus  in  the  neck  and  gently 
stimulate  the  proximal  end  with  elec- 
tricity. By  this  method  asthma  is  pro- 
duced in  the  right  lung  and  spasmodic 
contractions  in  the  right  half  of  the 
diaphragm.  We  must  look,  therefore,  for 
the  cause  of  asthma  in  some  tissue  or 
tissues  supplied  by  the  vagi  and  the  sym- 
pathetic nerves,  or  in  a  lesion  of  the 
nerves  themselves.  E.  Kingscote  (Brit. 
Med.  Jour.,  Oct.  13,  1900). 

The  four  above-mentioned  factors  are 
able  to  give  rise  to  the  pulmonary  and 
muscular  phenomena,  owing  to  the  un- 
toward accumulation  in  the  system  at 
large  of  (1)  products  of  metabolism 
which  fail  to  be  eliminated  through 
hffimatopoietic  or  renal  insufficiency, 
uric  acid,  acetone,  etc.;  (2)  extraneous 
toxics,  such  as  lead,  mercurv.  etc. 


Case  in  which  asthma  replaced  epilep- 
tic fits.  The  pent-up  nerve-storm,  instead 
of  discharging  itself  in  the  customary 
channel  in  an  epileptic  seizure,  expended 
its  energy  upon  the  bronchial  muscular 
fibre,  giving  rise  to  the  protracted 
asthmatic  phenomena.  After  many 
hours  it  exhausted  itself  by  way  of  an 
orthodox  "fit,"  thus  bringing  the  dis- 
turbance to  a  conclusion.  Francis  Tay- 
lor (Lancet,  June  10,  '92). 

An  excess  of  uric  acid  in  the  blood 
contracts  the  arterioles  all  over  the  body 
and  produces  high  arterial  tension. 
Asthma  represents  the  efl'eet  on  the 
thoracic  circulation  of  this  high  arterial 
tension,  while  migraine  and  epilepsy 
represent  its  eflfect  upon  the  circulation 
of  the  brain.  A.  Haig  (International 
Clinics,  vol.  iv,  '94). 

Nervous  asthma  is  usually  due  to  in- 
toxication. The  attacks  occur  at  night, 
because  the  urine  is  more  toxic  then 
than  in  the  day-time.  Huchard  (Revue 
Gen.  de  Clin,  et  de  Th6r.  Jour,  des  Prat., 
Feb.  22, '96). 

Five  eases  which  occurred  in  aged  pa- 
tients, all  of  them  showing  evidence  of 
arteriosclerosis  and  weakness  of  the 
cardiovascular  system,  and  a  number  of 
them  had  attacks  resembling  angina  pec- 
toris. The  essential  feature  of  the  case 
was  that  they  had  severe  attacks  of 
asthma  which  came  on  almost  solely  at 
night,  and  that  in  all  these  instances  the 
use  of  catheter  disclosed  a  certain  de- 
gree of  retention  of  urine,  and  the  evacu- 
ation of  the  bladder  caused  the  entire 
disappearance  of  the  dyspnoea  with  sur- 
prising rapidity.  Autointoxication  ^Aas 
probably  the  cause,  due  to  greater  diffi- 
culty in  emptying  the  bladder  when  the 
patients  are  at  rest  in  a  horizontol  posi- 
tion. Pawinski  (Eevue  de  M6d.,  Mar. 
10,  '99). 

Asthma  due  to  dyspepsia.  The  most 
typical  cases  occur  in  children  usually 
of  neurotic  inheritance.  To  suppose  that 
they  are  due  to  autointoxication  is  the 
most  easy  assumption,  but  the  ptomaines 
and  toxins  hitherto  isolated  for  the  most 
part  act  differently  upon  the  heart: 
slacken  it  instead  of  accelerating.  Prob- 
ably there  is  an  increased  bulbar  receptiv- 


518 


ASTHMA.    PROGNOSIS.    TREATMENT. 


Ity  in  these  cases,  and  reflexes  are  more 
easily  exciting  than  usual.  Acetonuria 
is  not  infrequently  present.  Strong  evi- 
dence of  the  dyspeptic  nature  of  the 
attacks  is  aflforded  by  the  cases  in  which 
the  exhibition  of  purgatives  or  emetics 
gives  prompt  and  immediate  relief. 
Moreover,  there  are  generally  signs  of 
dyspepsia;  for  example,  furred  tongue, 
foul  breath,  nausea,  and  vomiting. 
Treatment  should  be  directed  accord- 
ingly. Landi  (Clinica  Mod.,  An.  5,  No. 
24,  '99). 

Two  fatal  cases  have  proved  the  cor- 
rect personal  former  belief  that  the 
anatomical  findings  in  the  lumen  of  the 
bronchi  are  not  always  the  same.  There 
exists,  however,  a  bond  of  union  between 
them  all  in  the  abundant  epithelial  des- 
quamation. A.  Fraenkel  (Deut.  med. 
Woch.,  Apr.  6,  1900). 

Chronic  dyspeptic  asthma  witnessed  in 
5  cases.  The  acute  type  occurs  after 
meals  and  is  characterized  by  dyspnoea, 
cyanosis,  and  irregularity  of  the  pulse. 
In  the  chronic  type  there  is  continuous 
shortness  of  breath  on  slightest  exer- 
tion. Both  forms  j'ield  readily  to  treat- 
ment of  the  gastric  disorder.  No  par- 
ticular form  of  stomach  trouble  is  re- 
sponsible for  the  condition.  F.  H.  Mur- 
doch (N.  Y.  Med.  Jour.,  Jan.  12,  1901). 

Prognosis. — The  prognosis  of  asthma 
depends  upon  the  nature  of  its  under- 
lying cause.  Cases  of  reflex  asthma  in 
which  the  primary  disorder  is  easily 
reached  and  properly  treated, — such  as 
nasal  hypertrophies,  polyi,  aural  growths, 
etc., — are  frequently  cured  and  remain 
so,  provided  the  causatiye  affection  does 
not  remain.  The  prognosis  is  also  good 
in  young  subjects  with  well-formed 
chests  and  in  whom  direct  heredity  can- 
not be  traced.  In  all  others,  however, 
the  chances  of  recovery  are  very  limited. 

Death  rarely  ensues  from  spasmodic 
asthma,  but  its  complications  may  prove 
fatal. 

Treatment. — The  treatment  of  asthma 
consists  of  (1)  arrest  of  the  paroxysm; 
(2)    prevention    of    the    paroxysms    by 


measures  calculated  to  annul  the  effects 
of  exciting  factors;  and  (3)  removal  of 
the  pathological  conditions  forming  the 
basis  of  the  paroxysms. 

1.  Paeostsm.  —  Before  instituting 
measures  calculated  to  arrest  an  attack, 
the  nature  of  the  disorder  giving  rise  to 
dyspncea  as  a  symptom  must  be  carefully 
determined.  Were  a  paroxysm  found  to 
be  due,  for  instance,  to  a  cardiac  affec- 
tion, the  remedies  most  frequently  pre- 
scribed —  stramonium,  belladonna,  and 
the  various  anesthetics  —  would  prove 
dangerous.  When  the  presence  of  true 
asthma  is  ascertained  beyond  a  doubt, 
the  object  should  be  to  relieve  suffering, 
and  narcotics,  or  the  so-called  "depress- 
ants," are  indicated.  Two  important 
facts  must  be  borne  in  mind  by  the  prac- 
titioner, however,  namely:  the  danger 
presented  by  all  narcotics  to  give  rise 
to  habits  of  inebriety,  and  the  necessity 
of  giving  sufficiently  large  doses  to  pro- 
duce physiological  effects  if  satisfactory 
results  are  to  be  attained. 

The  bimeeonate  of  morphine,  ^/^  grain 
by  the  mouth,  or,  better  still,  10  minims 
of  Magendie's  solution,  given  hypoder- 
mically  (the  dose  varj'ing,  of  course,  with 
the  age  of  the  patient),  are  the  most 
satisfactory  agents  wh^n  rapid  effects  are 
necessary,  especially  if  combined  with 
atropia  (not  more  than  V120  grain  being 
given  in  any  ease).  Codeine  may  be  used 
instead  of  the  morphine  if  the  latter  pro- 
duces nausea.  These  remedies  present, 
as  objections,  however,  the  partial  sup- 
pression of  expectoration  in  some  cases, 
and  a  certain  amount  of  danger  in  cases 
of  Bright's  disease.  Strychnine  may  be 
.advantageously  added  to  stimulate  the 
vasomotor  system  and  equalize  the  cir- 
culation. 

Subcutaneous  injection  of  a  combina- 
tion of  strychnine  sulphate,  '/;„  grain, 
with    atropine    sulphate,   V^oo   grain,   re- 


ASTHMA.    TREATMENT. 


519 


peated    daily    or    as    necessary.      Mays 
(Philadelphia  Polyclinic,  Jan.  5,  '95). 

Chloral-liydrate  comes  next  in  order 
when  prompt  relief  is  required;  15  to  20 
grains  may  be  given  to  an  adult.  Marked 
cardiac  disorder  renders  this  drug  dan- 
gerous; the  heart  should  be  carefully 
examined. 

Chloroform  proves  rapidly  effective 
in  some  cases.  Fifteen  drops  in  a  half- 
tumblerful  of  water  to  which  a  tea- 
spoonful  of  syrup  of  orange-peel  has 
been  added  make  up  a  palatable  dose. 
Sulphuric  ether,  30  to  40  drops,  may  be 
used  in  the  same  way,  or  be  adminis- 
tered on  a  piece  of  sugar,  but  the  sudden 
volatilization  produced  by  the  heat  of 
the  stomach  causes  eructations  which  are 
unpleasant  to  the  patient.  Hoffmann's 
anodyne  (compound  spirit  of  nitrous 
ether),  1  drachm  in  half  a  tumblerful 
of  pure  water,  is  frequently  effective. 
The  dose  should  be  repeated  every  half- 
hour. 

During  a  paroxysm  the  following  is 
effective: — 

IJ  Tr.  opium,  1  drachm. 
Ether,  2  drachms. 

M.  Sig. :  Fifty  drops  at  intervals  of 
one-half  hour  until  the  spasm  is  relieved. 
Editorial  (Journal  de  Med.  de  Paris,  Apr. 
14, '97). 

For  the  relief  of  the  asthmatic 
paroxysms   a  combination   of 

I^  Morphine  sulphate,  ^U  to  V,  grain. 
Strychnine     sulphate,    V„o     to     V« 

grain. 
Hyoscine  hydrobromate,  '/.„„  grain, 
should  be  given  hypodermieally  at  bed- 
time. In  some  cases  its  repetitions  is 
unnecessary;  in  others  after  two  or 
three  injections  complete  relief  from  the 
attack  has  been  observed.  Considerable 
caution  must  be  exercised  as  to  its  repe- 
tition. S.  Solis-Cohen  (Phila.  Polyclinic, 
Oct.  9,  '97). 

Case  of  distressing  asthma  which  failed 
to  yield  to  all  treatment  until  adrenal 
substance    was    used.      Tablets    contain- 


ing 5  grains  each  were  prescribed  once, 
then  twice,  then  three  times  daily,  and 
finally  the  patient  for   a   time  took  90 
grains   daily.     A   striking   improvement 
shortly  became  manifest.     The  constant 
dyspnoea  first  disappeared,  then  the  par- 
oxysmal  nocturnal  attacks   became  less 
frequent  and  less  severe.     Recovery  was 
not  rapid,  but  was  continuous.    S.  Solis- 
Cohen    (Jour.   Amer.  Med.   Assoc,  May 
12,  1900). 
General  anaesthesia  is  sometimes  em- 
ployed to  advantage,  but  is  not  to  be 
recommended  unless  other  means  have 
failed.     Chloroform  inhalations  are  the 
most  effective.   Ether  irritates  the  larynx 
and  sometimes  causes  marked  distress. 

[When  general  anaesthesia  is  resorted 
to,  the  inhalations  should  not  be  vigor- 
ous at  the  start.  Severe  dyspnoea  may 
otherwise  be  induced  through  the  laryn- 
geal irritation  produced.  A  preliminary 
application  of  a  5-per-cent.  solution  of 
cocaine  to  the  nasal  cavities  greatly  in- 
creases the  efficacy  of  the  anaesthetic 
inhaled. 

Anaesthetics  are  dangerous  in  cases 
of  infraglottic  thickening,  symptoms  of 
which  greatly  resemble  chronic  asthma. 
Hill  reported  a  case  in  which  death  very 
nearly  ensued  through  the  use  of  ether. 
Sajous.] 

Iodide  of  ethyl,  6  or  8  drops,  inhaled 
from  a  piece  of  lint.  Thorowgood  (Med. 
Chronicle,  Mar.,  '95). 

Spray  chloride  of  methyl  rapidly  over 
the  back  of  patient.     The  attack  ceases 
in  a  few  moments;    if  not,  light  spraying 
of  upper  part  of  the  chest.     If  the  skin 
is    delicate,    cover   the    parts    with    fine 
gauze.    Tsakiris  (Gaz.  des  Hop.,  Mar.  12, 
'95). 
The  application  to  the  mucous  mem- 
brane of  the  nasal  cavities  of  a  5-per- 
cent, solution  of  cocaine  is  highly  recom- 
mended by  Dieulafoy. 

Pure  carbonic-acid  gas,  inhaled  for 
from  5  to  10  minutes  at  a  time,  using  fre- 
quently, proves  successful.  The  benefit 
is  probably  due  to  the  inhibitory  effect 
of  the  gas  on  the  larynx, — an  abolition 
of  the  reflex  sensibility ;  it  appears  to  cut 
the  paroxysms  short  when  given  during 


520 


ASTHMA.    TREATMENT. 


the  attacks.     Weill  (La  France  Med.  et 
Paris  M6d.,  Mar.  8,  '88). 

Simple  method  of  manufacturing  car- 
bonic-acid gas:  In  a  bottle  closed  with 
a  rubber  stopper  a  tube  is  passed.  Three 
drachms  of  tartaric  acid  and  four 
drachms  of  bicarbonate  of  soda  (suffi- 
cient to  produce  four  or  five  quarts  of 
carbonic  acid)  are  then  placed  in  the 
bottle.  The  patient  places  the  tube  in 
his  mouth,  and  the  gas  is  very  easily 
inhaled  on  account  of  its  force  of  ex- 
pansion. This  can  also  be  done  with  a 
common  glass.  Chabannes  (La  Semaine 
Med.,  May  27,  '88). 

The  smoke  obtained  from  antispas- 
modic remedies — nitre,  stramonium,  to- 
bacco, hyoscyamus,  and  belladonna — is 
efficacious  in  cases  in  which  emphysema 
is  not  marked. 

Cigarettes  may  be  made  of  paper 
soaked  in  a  saturated  solution  of  nitrate 
of  potassium  and  belladonna.  The  sheets 
are  allowed  to  dry,  and  are  then  rolled 
into  the  shape  of  cigarettes. 

An  effective  cigarette  may  also  be 
made  of  equal  parts  of  lobelia,  stramo- 
nium, and  green  tea-leaves,  or  of  stra- 
monium-leaves and  ordinary  tobacco. 
Tobacco  sometimes  proves  useful  alone 
where  it  has  not  been  previously  used. 

The  famous  hyoscyamus  and  stramo- 
nium cigarettes  of  Espic  are  composed 
of  the  following  agents: — 

IJ  Belladonna-leaves,  6  grains. 
Hyoscyamus-leaves,  3  grains. 
Stramonium-leaves,  3  grains. 
Extract  of  opium,  ^/^  grain. 
Cherry-laurel  water,  q.  s. — M. 

The  most  active  principle  in  the  above 
combination  being  pyridine,  the  cigar- 
ette may  be  replaced  by  inhalations  of 
the  drug,  10  to  15  drops  being  inhaled 
from  a  handkerchief.  The  following 
method  of  using  pyridine,  however,  is 
the  most  effective: — ■ 

The  patient  being  in  a  small  room,  a 


saucer  containing  pyridine  is  put  some 
distance  from  him.  He  is  allowed  to 
inhale  the  fumes  about  half  an  hour. 
(Germain  See,  Chicot,  Kelamin,  Dieu- 
lafoy.) 

Hyoscyamine,  Vi^,,  to  ^/^^o  grain, 
given  hypodermically,  is  recommended 
by  Musser. 

Paraldehyde,  30  grains  hourly  until 
improvement  is  noted,  is  recommended 
by  Mackie  and  others. 

Paraldehyde  administered  in  a  number 
of  cases  of  idiopathic  asthma  and  other 
forms  of  spasmodic  dyspnoea  with  satis- 
factory results.  It  not  only  relieves  the 
spasm,  but  it  induces  tranquil  refresh- 
ing sleep  without  any  objectionable 
after-effects.  Besides,  no  evil  results  fol- 
low a  prolonged  use  of  paraldehyde;  it 
does  not  give  rise  to  a  habit,  and  on 
this  account  it  is  a  much  more  desirable 
drug  than  morphine  and  chloral.  Iodide 
of  potassium  and  tincture  of  lobelia,  as 
a  rule,  do  much  to  relieve  the  bronchitis 
and  to  lessen  the  spasm,  but  their  effect 
is  immensely  increased  by  securing  sleep 
and  the  prevention  of  the  nocturnal 
spasms  by  means  of  paraldehyde.  The 
drug  occasionally  causes  sickness,  and 
for  this  reason  it  proved  of  no  use  in  a 
severe  case  of  long-standing  bronchitis 
and  emphysema.  Its  disagreeable  pun- 
gent taste  makes  it  objectionable  to  chil- 
dren and  nervous  patients,  but  it  is  well 
disguised  in  cinnamon-water  and  tincture 
of  orange-peel.  It  acts,  as  a  rule,  so 
rapidly  that  the  dose  ought  to  be  taken 
after  the  patient  has  gone  to  bed.  In 
adults  it  is  best  to  begin  with  a  dose  of 
60  minims,  and  the  same  dose  has  equally 
good  hypnotic  effect  when  it  has  been 
taken  for  months.  Alexander  MacGregor 
(Lancet,  Feb.  11,  '99). 

Passion-flower  (passiflora  incarnata) 
possesses  hypnotic  and  antispasmodic 
powers,  and  in  sufficient  dosage  it  would 
probably  act  as  a  narcotic  poison.  Even 
in  moderate  doses  it  may  in  some  cases 
provoke  nausea  and  emesis.  The  com- 
bination of  relaxant  influences  gives  it 
peculiar  value  in  allaying  asthmatic 
paroxysms  and  in  preventing  their  full 


ASTHMA.     TREATMENT. 


521 


development.  It  may  be  given  in  tinc- 
ture or  fluid  extract.  The  dose  is  from 
10  to  30  minims  -well  diluted  and  given 
from  every  ten  minutes  to  every  half- 
hour  until  relief  is  experienced,  emesls 
caused,  or  drowsiness  induced.  Half  a 
fluidounce  of  the  fluid  extract  has  per- 
sonally never  been  exceeded  in  the 
course  of  two  hours.  Patients  have 
fallen  asleep  after  6  doses  of  10  to 
20  drops  each,  given  every  ten  or  fifteen 
minutes,  or  after  a  single  dose  of  1 
fluidrachm.  In  two  out  of  eight  cases 
its  use  produced  but  slight  mitigation 
of  distress,  and  was  abandoned.  In  six 
cases  rebellious  to  other  methods  it  gave 
prompt  relief.  S.  Solis-Cohen  (Amer. 
Medicine,  Sept.  14,  1901). 

Antipyrine,  15  grains  being  given 
every  three  hours  until  the  access  is 
relieved,  proves  especially  effective  in 
anffimic  cases;  but  such  large  doses  are 
toxic  in  some  cases.  Again,  it  sometimes 
does  harm  in  increasing  the  severity  of 
subsequent  attacks,  particularly  in  a  case 
associated  with  bronchitis. 

Caffeine  citrate — 1  to  5  grains,  dis- 
solved in  warm  water  every  four  hours 
—  is  especially  effective  in  bronchial 
asthma  and  in  bronchitis  associated  with 
spasm  of  the  bronchial  tubes. 

There  are  two  quite  distinct  forms  of 
the  affection,  namely:  true  spasmodic 
asthma,  which  is  benefited  by  citrate  of 
caffeine  and  fuming  inhalations,  and 
cardiac  asthma,  in  which  ordinary  car- 
diac drugs  do  good  for  a  time  and  which 
later  on  benefit  by  oxygen  inhalations, 
whereas  fuming  antispasmodics  do  no 
good.  Thorowgood  (London  Medical  So- 
ciety, Mar.,  '98). 

Glonoin,  composed  of  1  part  of  nitro- 
glycerin to  99  parts  of  alcohol,  given  in 
doses  of  Vioo  to  Vso  grain,  acts  rapidly 
in  some  cases;  but  even  in  these  its 
effects  are  frequently  only  temporary. 
From  2  to  5  drops  of  a  1  to  100  solution 
of  nitroglycerin  (if  there  is  but  little 
emphysema  and  no  cardiac  disorder)  are 


recommended  by  Woodbury  and  Hoff- 
mann. 

Peroxide  of  hydrogen,  sprayed  over 
the  patient,  the  operator  standing  at 
some  distance,  has  been  used  with  suc- 
cess by  Warren. 

Asaprol,  1  to  1  V2  drachms  in  powder 
or  in  solution,  is  a  new  drug  recom- 
mended by  Lewin.  Laborde's  rhythmic 
traction  of  the  tongue  might  be  tried 
when  no  remedies  are  within  reach.  The 
organ  being  held  by  the  fingers,  covered 
by  a  napkin,  it  is  drawn  out  at  regular 
intervals,  eighteen  to  twenty  times  a 
minute,  imitating  the  respiratory  rhythm. 

2.  Prevention  of  Paroxysm.  —  As 
already  stated,  the  phenomena  observed 
in  the  chest-walls  and  lungs  may  be  due 
to  reflex  action,  the  primary  factors  of 
which  may  be  located  in  the  naso-pharyn- 
geal  tract,  the  ear,  the  digestive  tract, 
and  the  genital  organs. 

Careful  examination  of  all  the  organs 
becomes,  therefore,  imperative.  The  nose 
and  stomach  are,  doubtless,  most  fre- 
quently at  fault.  In  the  nasal  cavities 
the  lesions  met  with  in  the  majority  of 
cases  are  nasal  polypus,  deflected  septum, 
and  turbinal  hypertrophy.  Active  meas- 
ures to  remove  any  of  these  abnormalities 
should  be  instituted  whenever  found, 
although  they  may  not  apparently  inter- 
fere with  the  physiological  functions  of 
the  nose. 

That  permanent  relief  is  to  be  ex- 
pected in  one-half  of  the  cases  cannot 
be  affirmed.  An  average  of  about  30  per 
cent.,  however,  probably  represents  the 
cures  obtained  by  rhinologists  at  large. 

Many  cases  seen  in  which  the  removal 

of  mucous  polypi  or  enlarged  turbinated 

bodies  from  the  nasal   passages  seemed 

to  result  in  a  cure  for  a  time,  but  the 

•    cures  were  not  permanent, — the   attack 


522 


ASTHMA.     TREATMENT. 


of  asthma  returned  sooner  or  later. 
Beverly  Robinson  (N.  Y.  Med.  Jour., 
Apr.  19,  '96). 

Disorders  of  digestion,  by  serving  as 
preliminary  factors  of  imperfect  metab- 
olism, very  frequently  act  as  starting- 
points  of  paroxysms  in  asthmatic  indi- 
viduals. Indeed,  the  majority  of  patients 
soon  learn  that  certain  articles  of  food 
and  any  indiscretion  as  to  quantity  or  as 
to  the  time  of  the  day  at  which  aliments 
are  partaken  of  may  give  rise  to  an  ex- 
acerbation of  their  trouble.  Experience 
teaches  them  that  the  greatest  discretion 
should  be  observed;  that  easily  digested 
food  should  alone  be  taken,  especially 
toward  evening;  and  that  wines  and  alco- 
holic beverages  had  best  be  avoided,  ow- 
ing to  their  inhibitory  influence  over  the 
various  digestive  processes.  Gaseous  liq- 
uids are  also  pernicious  by  causing  dila- 
tation of  the  stomach  and  pressure  upon 
the  overlying  diaphragm.  Butcher's 
meat,  greasy  soups,  coffee,  sweets,  and 
other  substances  tending  to  the  forma- 
tion of  urea  are  contra-indicated.  Milk, 
fish,  eggs,  and  vegetables  (except  beans 
and  rye)  should  form  the  bulk  of  the 
patient's  diet. 

There  can  be  no  doubt  that  uric- 
acidEemia,  when  it  contracts  the  arte- 
rioles, may  practically  suspend  entirely 
gastro-intestinal  digestion  and  absorp- 
tion and  allow  putrefactive  processes  to 
take  their  place;  in  this  way  urio- 
acidsemia  causes  dyspepsia.  But  dys- 
pepsia, on  the  other  hand,  will  also 
cause,  or  increase,  uricaeidsemia.  More 
or  less  complete  arrest  of  digestion  and 
absorption  promptly  causes  a  fall  In 
urea  and  a  corresponding  fall  in  the 
acidity  of  the  urine;  the  alkalinity  of 
the  blood  is  increased,  and  any  uric  acid 
within  its  reach  is  at  once  taken  up  in 
solution.  Haig  (International  Clinics, 
vol.  iv,  '94). 

The  treatment  should,  above  all,  be 
alimentary.  A  milk  and  partly  vege- 
tarian diet  should  occupy  the  first  place. 


This  succeeds  where  potassium  iodide 
fails.  Huchard  (Revue  66n.  de  Clin,  et 
de  Ther.  Jour,  des  Praticiens,  Feb.  22, 
'96). 

In  four  cases  of  asthma  compression  of 
the  pneumogastric  nerve,  at  the  surface 
of  the  neck,  employed.     The  compression 
was  accomplished  by  means  of  a  finger 
and  yielded  relief  within  a  few  minutes, 
even   to  complete   disappearance   of   the 
attack  of  dyspnoea.    A.  de  Miranda  (Sem. 
Med.,  xviii,  p.  110). 
3.  CuEATiVE    Measures.  ■ —  The    re- 
moval of  whatever  organic  disorder  that 
may  be  present,  whether  located  in  the 
nasal  cavities,  stomach,  genital  tract,  etc., 
is,  of  course,  the  primary  feature  of  the 
treatment  of  a  case  when  the  existence 
of  any  such  disorder  can  be  distinctly 
established.     The  chances   of  cure  are 
greatly  increased  when  a  localized  affec- 
tion is  present,  even  if  only  concomi- 
tantly,  as  successful  treatment   of  the 
latter  entails  the  removal  of  a  disturbing 
element  of  which  the  sympathetic  system 
at  large,  and  the  vasomotors  in  particu- 
lar, bear  the  brimt.    Diathetic  affections, 
— syphilis,  for  instance, — and  any  of  the 
conditions  mentioned  of  which  uricacid- 
semia  is  the  most  prominent  type,  also 
require  active  interference.   Considerable 
improvement,  and  in  some  cases  cure, 
may  be  expected  if  a  proper  diagnosis  of 
the  primary  etiological  factor  is  estab- 
lished and  the  proper  measures  instituted. 

Treatment  based  on  the  statements  of 
Haig  and  others,  that  the  contraction  of 
the  bronchi  and  arterioles  is  often  due 
to  the  accumulation  of  uric  acid  in  the 
blood.  The  biurate  crystals,  by  their 
points,  set  up  a  reflex  irritation  of  the 
terminal  branches  of  vagi  in  the  bron- 
chial mucous  membrane.  Frequency  of 
attacks  is  in  proportion  to  amount  of 
uric  acid.  Thiolin,  the  laxative  salt 
of  lithium,  given  as  follows:  A  tea- 
spoonful  in  a  cup  of  hot  water  every 
three  hours  until  free  catharsis  results; 
thereafter  the  same  dose  is  given  once  a 
day  on  rising.     When  urine  is  alkaline. 


ASTHMA.     TREATMENT. 


533 


medication  is  omitted  foi'  two  days.  In 
addition,  the  diet  is  to  be  limited, 
strongly  nitrogenous  food  being  inter- 
dicted. G.  A.  Gilbert  (St.  Louis  Med. 
and  Surg.  Jour.,  vol.  Ixviii,  p.  125,  1900). 

Underlying  the  varieties  of  primary 
-disorders,  to  which  mention  has  just 
been  made,  are  others  that  may  be 
classed  as  complications.  These  are  usu- 
ally present  whatever  may  be  the  primary 
cause  of  the  disease.  Most  prominent 
among  these  are:  1.  The  general  neu- 
rosis forming  the  basis  of  the  asthmatic 
paroxysms,  which  may  have  assumed  a 
chronic  type  through  depravity  of  the 
nerve-centres.  2.  Inflammatory  lesions 
of  the  bronchial  tract,  which,  through 
the  supplementary  congestion  induced  by 
an  unusual  atmospheric  condition  or  a 
dietetic  error,  may  suddenly  cause  a  par- 
oxysm. 3.  Malformation  of  the  thorax, 
— the  "barrel-chest,"  due  to  excessive 
distension,  which  may  prevent  the  ex- 
pttlsion  of  a  sufficient  amount  of  tidal 
air  and  interfere  with  oxygenation, — a 
condition  present  in  the  great  majority 
of  cases  and  a  potent  element  in  the 
causation  of  suffering. 

When,  therefore,  judicious  treatment 
of  any  abnormal  condition  of  the  upper 
respiratory,  digestive,  or  genito-urinary 
tract,  or  the  circulatory  and  hepatic  sys- 
tems does  not  yield  satisfactory  results,- 
it  is  probably  due  to  the  fact  that  either 
one,  two,  or  all  three  of  the  conditions 
oittlined  complicate  the  case.  In  the 
vast  majority  of  cases  of  long  standing 
the  entire  symptom-complex  is  present: 
a  pernicious  cycle  that  only  persistent 
effort  on  the  part  of  the  physician  can 
command. 

The  neurotic  asthenia  may  be  said  to 
be  present  in  all  cases  of  asthma.  This 
is  met  most  satisfactorily  by  strychnine 
in  increasing  doses,  beginning  for  adults 
with    ^/cfi    grain    after    each    meal    and 


gradually  bringing  the  dose  up  to  V^o 
grain,  during  a  period  covering  two 
months. 

The  case  should,  of  course,  be  care- 
fully watched,  and,  if  the  physiological 
effects  of  the  drug  appear,  the  dose  of 
strychnine  should  be  reduced.  Static 
electricity,  by  stimulating  the  peripheral 
vasomotors,  greatly  enhances  the  action 
of  the  strychnine,  and,  in  fact,  is  a  nec- 
essary accompaniment.  Daily  sittings  of 
fifteen  minutes  each  are  required  to  sus- 
tain the  beneficial  effects  obtained. 

When  bronchial  lesions  are  present, — 
they  are  invariably  discernible  in  true 
asthma, — the  treatment  should  begin  by 
a  course  of  iodide  of  potassium,  rapidly 
increasing  the  dose  from  5  to  30  grains 
three  times  a  day.  To  avoid,  as  much  as 
possible,  gastric  disturbances,  it  should 
be  administered  in  not  less  than  a  half- 
tumblerful  of  pure  water  at  first,  and  in 
a  tumblerful  when  larger  doses  are  to 
be  taken.  Fowler's  solution,  3  minims 
three  times  a  day,  generally  counteracts 
the  eruption  and  other  unpleasant  effects 
of  iodide  of  potassium,  and  should  be 
administered  simultaneously  if  need  be. 
After  a  couple  of  months  the  strychnine 
and  static  electricity  course  may  be  be- 
gun. Iodide  of  potassium  is  contra-indi- 
cated in  cases  in  which  there  is  a  tend- 
ency to  hemoptysis,  or  when  there  is  an 
infraglottic  disorder. 

If  the  opinion  of  Landouzy  that  true 
asthmatics  not  infrequently  have  an  ele- 
ment of  tuberculosis  is  well  founded, 
there  is  reason  to  think  that  other  toxins 
also  may  promote  the  asthmatic  symp- 
tom-complex, and  especially  the  strepto- 
coccic toxin.  Hence  an  explanation  of 
the  cure  of  asthma  in  certain  cases  by 
antistreptococcic  serum.  Boucheron  (Tri- 
bune Mgd,,  May  4,  '94). 

Atropine  strongly  recommended  in 
bronchial  asthma.  The  dose  at  first  is 
Vi:o  grain  daily  by  the  mouth;  the  dose 
is  increased  by  this  amount  every  two 


524 


ASTHMA.    TREATMENT. 


or  three  days  until  the  daily  dose  of 
Vio  of  a  grain  is  reached.  Then  the 
amount  is  gradually  diminished,  the 
duration  of  the  treatment  averaging  four 
to  six  weeks.  This  should  he  repeated 
every  six  months,  but  throughout  less 
time  and  with  smaller  doses.  Carl  von 
Noorden  (Ther.  Monats.,  H.  10,  S.  539, 
'98). 

Experience  with  atropine  in  doses  of 
'/i2o  to  'Ao  grain,  hypodermically,  during 
the  attack  has  been  most  satisfactory. 
It  did  not  always  control  the  attack,  to 
be  sure,  but  the  action  was  usually  ex- 
tremely prompt  and  gratifying;  the 
dyspnoea,  in  particular,  soon  disappear- 
ing and  the  distension  of  the  lungs 
rapidly  becoming  less  marked.  F.  Eiegel 
(Deut.  med.  Woch.,  Oct.  12,  '99). 

The  barrel-chest,  when  due  to  the  dis- 
ease, is  only  met  with  in  advanced  cases. 
But,  whether  present  or  not,  the  condi- 
tions acting  as  its  causes  are  generally 
present,  namely:  weakness  of  the  mus- 
cles concerned  in  the  performance  of 
the  respiratory  act,  including  the  dia- 
phragm. The  treatment  of  all  cases  of 
asthma  should,  therefore,  include  meas- 
ures designed  to  increase  nutrition  of 
these  miiscles  and  the  activity  of  their 
nervous  supply.  Strychnine  fulfills  the 
latter  objects,  but  it  must  be  assisted 
by  complementary  measures  designed  to 
localize,  as  it  were,  its  beneficial  influ- 
ence. For  the  superficial  muscles  of  the 
chest,  massage,  first  along  the  intercostal 
spaces,  then  over  the  large  muscles,  the 
deltoids  especially;  the  outline  of  the 
muscles  shoidd  be  borne  in  mind  and  the 
active  pressure  exerted  along  the  mus- 
cular fibres  toward  the  arterial  trunk 
supplying  each  set.  For  the  diaphragm 
the  faradic  current  alone  is  of  service, 
the  negative  pole  being  applied  over  the 
course  of  the  phrenic  nerve  just  above 
the  clavicle  and  the  positive  over  the 
xiphoid  cartilage.  The  sponges  being 
fully  moistened  with  salt-water  and  ap- 
plied, the  patient  is  directed  to  empty 


his  lungs  of  air,  then  to  only  inflate  them 
partially,  and  to  continue  this  restricted 
respiratory  act  during  the  entire  sitting, 
— about  five  minutes  at  first,  then  ten 
minutes.  The  oftener  this  procedure  will 
be  undertaken,  the  sooner  will  satisfac- 
tory results  be  attained.  At  home  the 
patient  will  enhance  the  effects  produced 
by  a  daily  calisthenic  exercise,  consisting 
in  bringing  the  fists  up  to  the  shoulders 
and  approximating  the  elbows  anteriorly 
as  much  as  possible  with  each  expiration. 
Chairs  have  been  invented  by  means  of 
which  the  exaggerated  expansion  of  the 
thorax  may  be  counteracted. 

Posterior  portion  of  chest  rapped  quite 
violently  until  the  entire  thorax  is  set 
into  violent  vibration.  This  improves  the 
circulation,  favorably  influences  the  em- 
physema, and  betters  the  nutrition  of 
the  lung.  Goebel  (Deut.  med.  Woch., 
Apr.  7,  '92). 

Asthma  is  due,  in  part,  to  a  deficient 
supply  of  oxygen  to  respiratory  centres; 
training  of  respiration,  carried  out  by 
practicing  respiratory  movements  needed 
to  carry  tidal  air  through  the  lungs,  is 
recommended.  Marcet  (Lancet,  July  13, 
'95). 

When  a  fall  in  the  barometric  pressure 
takes  place,  the  asthmatic  subject  de- 
velops and  passes  through  a  series  of 
symptoms  of  an  identical  nature  to  those 
which  are  observed  when  men  are  sud- 
denly removed  from  additional  atmos- 
pheric pressures  to  the  normal.  This 
force,  which  difTers  so  vastly  in  its  in- 
tensity, established  a  series  of  symptoms 
which  vary  only  in  their  severity  and 
immediate  results.  Should  death  take 
place  under  any  of  the  conditions  men- 
tioned, and  the  post-mortem  appearances 
be  compared  with  those  observed  in 
death  from  carbonic-acid  poisoning  di- 
rect, their  further  identity  will  be  ap- 
parent. J.  C.  Bowie  (Edinburgh  Med. 
Jour.,  May,  '97). 

In  case  of  hysterical  diaphragmatic 
asthma  faradization  of  the  phrenies  and 
practice  in  voluntary  respiration  were 
soon  followed  by  improvement,  but  the 
dyspnceie  motions  returned  whenever  the 


ASTHMA.     TREATMENT. 


525 


patient  felt  he  was  being  observed. 
Finally,  complete  recovery  was  obtained. 
E.  Earth  (Berliner  klin.  Woch.,  Nos.  42, 
43,  '98). 

As  a  result  of  clinical  observation,  fol- 
lowing conclusions  reached:  1.  The 
spasm  of  the  respiratory  passages  may 
be  produced  voluntarily  by  the  majority 
of  asthmatic  patients  and  by  many  nor- 
mal individuals.  2.  Almost  all  asth- 
matics can  control  the  spasms  even  dur- 
ing an  attack,  but  certainly  during  the 
period  of  remission.  3.  The  muscles  of 
the  respiratory  passages  are  either  under 
the  control  of  the  will  or  may  be  brought 
under  such  control.  As  a  consequence  of 
these  conclusions  the  importance  of  re- 
spiratory gymnastics  for  asthmatic  pa- 
tients is  patent.  The  number  of  respira- 
tions per  minute  must  be  reduced  and 
expirations  performed  slower  and  more 
completely.  The  spasm  of  the  muscles 
will  thus  be  controlled.  The  speech  must 
be  regulated  and  while  speaking  the  pa- 
tient must  inspire  slowly  and  deeply. 
The  asthmatic  must  learn  to  maintain 
the  proper  tension  of  the  muscles  of  the 
neck,  chest,  and  abdomen.  Talma  (Ber- 
liner klin.  Woch.,  No.  52,  '98). 

Personal  method  of  treatment  in  those 
cases  of  asthma  combined  with  cardiac 
dilatation  consists  in  a  modification  of 
the  Schott  treatment  with  the  inhala- 
tion tn  ice  daily  of  free  oxygen-gas.  The 
gas  seems  to  relieve  the  paroxysms  by 
supplying  the  oxygen  of  which  the  sys- 
tem is  in  need.  Kingscote  (Medical 
News,  May  21,  '98). 

Compressed  air,  the  patient  being 
placed  in  pneumatic  air-chamber  in 
which  the  air  has  been  condensed,  is 
of  great  value  in  bronchial  asthma  and 
secondary  emphysema.  Unfortunately, 
the  apparatus  required  is  so  bulky  and 
expensive  that  it  is  hardly  ever  at  the 
disposal  of  the  physician.  Expiration 
into  rarefied  air  is  of  signal  value  in 
spasmodic  asthma,  the  apparatuses  of 
Waldenburg  and  Solomon  Solis-Cohen 
being  especially  efficient  for  the  purpose. 
Rarefied  compressed  air  used  to  a  con 
siderable   extent,  invariably  with   excel 


lent  results.  Contra-indications:  Valv- 
ular disease  of  the  heart,  extensive 
cardiac  dilatation,  fatty  degeneration  of 
the  heart,  or  atheromatous  degeneration 
of  the  arteries.  Williams  (Amer.  Jour, 
of  the  Med.  Sciences,  Aug.  5,  '95). 

[I  employ  the  Guillemin  hydraulic  ap- 
paratus, owing  to  the  fact  that  no 
weights  are  required  and  because  its 
diminutive  size  causes  it  to  occupy  but 
little  room  as  compared  to  other  instru- 
ments.    Sajous.] 

Strophanthus,  10  grains  three  times 
a  day,  has  been  credited  with  curative 
properties,  but  the  best  that  can  be  said 
of  this  drug  is  that  it  seems  to  lengthen 
the  interparoxysmal  periods. 

Strophanthus,  in  lO-grain  doses,  less- 
ens the  excitability  of  the  vagus,  given 
three  times  daily  at  intervals  for  some 
time;  arrests  asthmatic  attacks  for  a 
long  period.  Drzew-iecki  (Le  Bull.  M§d., 
Jan.  22,  '90). 

Intralaryngeal  injections  for  the  pur- 
pose of  reducing  the  catarrhal  process 
of  the  bronchial  mucous  membrane  have 
been  followed  by  satisfactory  results. 

Intralaryngeal  injections  of  the  follow- 
ing solutions  are  used,  the  quantity  of 
the  solutions  injected  and  the  amount 
of  the  agents  contained  in  each  injection 
being  in  accordance  with  the  patient's 
age  and  condition.  One  drachm  will  be 
sufficient  for  a  child  from  5  to  10  years 
of  age,  2  drachms  from  10  to  15;  after 
this,  from  3  to  5  drachms  will  suffice  at 
each  sitting. 

First  solution:  a  5-,  10-,  15-,  or  20- 
per-cent.  solution  of  menthol  in  almond- 
oil. 

Second  solution:  2  to  5  minims  of  a 
2  Vi-per-cent.  solution  of  pure  crystals 
of  iodine  in  almond-oil,  added  to  each 
drachm  of  the  first  solution. 

Third  solution:    5  minims  of  a  10-per- 
cent, solution  of  oil  of  hops  in  almond-oil 
added  to  each  drachm  of  the  first.    J.  C. 
Bowie  (Edinburgh  Med.  Jour.,  May,  '97). 
When  the  asthma  occurs  in  connection 
with  pregnancy  viburnum  prunifolium  is 
a  valuable  remedy.     If  there  should  be 


536 


ASTIGMATISM. 


any  indication  of  abortion,  chloral-hy- 
drate may  be  administered  simultane- 
ously. 

Climate  is  thought  to  bear  consider- 
able influence  upon  the  explosion  of 
asthmatic  paroxysms.  The  fact  is  that 
very  few  cases  are  permanently  cured  by 
a  change  of  residence,  and  that  prac- 
tically all  are  momentarily  benefited  by 
any  change  they  may  make.  Thus,  re- 
moval from  the  purest  mountain-air  to 
the  dusty  air  of  a  large  city  is  frought 
with  momentary  relief.  It  is  probable 
that  the  change  of  diet  and  habits  has 
much  to  do  with  the  result  attained,  un- 
less the  paroxysms  are  greatly  under  the 
influence  of  bronchial  catarrh,  when  the 
removal  from  a  cold  and  damp  climate 
to  a  warm  and  dry  one  may  prove  of 
lasting  benefit. 

In  seeking  for  a  climate  it  is  well  to 
remember  that  for  a  time  immunity 
from  attacks  may  be  apparent,  but 
finally  acclimatization  takes  place  and 
the  symptoms  reappear.  Briigelmann 
(Ther.  Monat,  H.  2,  S.  74,  '97). 

Case  of  a  physician  who  changed  his 
residence  and  practice  several  times  dur- 
ing his  life,  on  account  of  asthma,  and 
who  finally  got  relief  by  going  back  to 
the  place  from  which  he  started.  F.  I. 
Knight  (Boston  Med.  and  Surg.  Jour., 
Mar.  25,  '97). 

While  Arizona  stands  first  as  a  cli- 
mate for  all  respiratory  diseases,  Tuc- 
son heads  the  list  of  its  cities  for  such 
patients.  It  has  an  elevation  of  about 
4000  feet;  its  annual  rain-fall  is  from  8 
to  10  inches;  its  mean  average  annual 
humidity,  36  per  cent.  It  is  free  from 
wind,  dust,  and  sudden  changes  of  tem- 
perature. Robert  Bell  (Boston  Med. 
and  Surg.  Jour.,  Apr.  25,  1901). 

Chaeles  E.  de  M.  Sajous, 

Philadelphia. 

ASTIGMATISM.— From  Gr.,  a,  priv.; 
and  GTiy/xa,  a  point.  This  word,  pro- 
posed by  Dr.  Whewell,  has  been  adopted. 


with  slight  modification,  in  all  modern 

languages. 

Astigmia,  from  a,  and  artyix-ij,  is  pro- 
posed to  replace  it,  as  being  etymologic- 
ally  better  and  shorter,  although  some 
of  the  derivative  words  would  be  longer. 
Georges  Martin  (Ann.  d'Oeul.,  Mar.,  '95). 

Definition.  —  That  error  of  refraction 
by  reason  of  which  rays,  coming  from 
a  single  point  and  passing  through  the 
refractive  surfaces  of  the  eye,  are  not 
turned  toward  a  single  point,  and,  there- 
fore, cannot  be  perfectly  focused  on  the 
retina. 

Irregular  Astigmatism. 

Definition. — The  form  of  astigmatism 
arising  when  one  or  more  of  the  refract- 
ive surfaces  of  the  eye  is  irregular;  so 
that  rays  passing  through  different  parts 
of  these  surfaces  are  turned  in  various 
directions  and  can  never  be  brought  to  a 
perfect  focus. 

Symptoms. — There  is  imperfect  vision, 
the  blurring  being  proportioned  to  the 
degree  of  the  defect  and  the  size  of  the 
pupil,  and  affecting  the  seeing  at  all  dis- 
tances and  all  times.  An  eye  subject  to 
this  defect  is  permanently  "weak,"  can- 
not attempt  work  requiring  very  accu- 
rate seeing,  and  is  liable  to  be  strained 
in  reading,  sewing,  etc.  The  irregularity 
of  surface  is  generally  accompanied  by 
more  or  less  haziness  or  opacity.  This 
may  be  the  opacity  remaining  in  the 
cornea  when  irregular  astigmatism  has 
been  caused  by  corneal  inflammation,  or 
it  may  be  an  opacity  of  the  lens,  when 
such  astigmatism  is  the  forerunner  of 
cataract. 

Pronounced  irregular  astigmatism 
causes  monocular  diplopia,  or  polyopia. 
A  lamp-flame  or  the  moon  at  night  is 
seen  multiplied,  the  different  images  of 
it  usually  overlapping  each  other  more 
or  less.  It  also  shows  itself  by  the  dis- 
tortion of  letters,  and  in  the  appearance 


ASTIGMATISM.     IRREGULAR.     ETIOLOGY.     TREATMENT. 


527 


of  additional  lines  about  or  upon  them, 
plain  type  being  made  to  appear  like 
fancy  type.  The  "rays"  which  appear  to 
proceed  from  a  point  of  bright  light,  as 
a  star  or  a  distant  electric  lamp,  are  due 
to  irregular  astigmatism.  An  eye  free 
from  astigmatism  would  see  a  star  as  a 
mere  point  of  light. 

Etiology.  —  Some  irregular  astigma- 
tism is  present  in  all  normal  eyes.  When 
it  causes  no  impairment  of  vision,  below 
the  usual  standard  of  20-xx,  it  is  called 
normal.  Normal  irregular  astigmatism 
is  generally  caused  by  the  inequality  of 
curvature  in  the  periphery  of  the  dilated 
pupil,  this  being  cut  off  when  the  pupil 
contracts. 

The  form  of  irregular  astigmatism  in 
which  rays  piercing  the  cornea  in  the 
same  meridian,  but  at  different  distances 
from  the  centre,  are  differently  refracted, 
while  rays  piercing  it  in  different  merid- 
ians, but  at  the  same  distance  from  the 
centre,  are  equally  refracted,  is  called  the 
"symmetrical  aberration"  of  the  eye.  It 
is  "positive"  if  the  rays  are  most  re- 
fracted at  the  edge  of  the  pupil.  This 
commonly  depends  upon  increased  curva- 
ture of  the  periphery  of  the  lens.  It  is 
"negative"  when  the  rays  are  least  re- 
fracted at  the  edge  of  the  pupil,  from  the 
flattening  of  the  periphery  of  the  cornea. 
Conical  causes  a  form  of  high  negative 
aberration.  E.  Jackson  (Trans.  Amer. 
Ophthal.  Soc,  '88). 

Even  when  not  excluded  by  the  iris, 
such  astigmatism  may  not  cause  imper- 
fect vision,  because  the  distinct  retinal 
image  may  be  formed  from  a  small  part 
of  the  light  entering  the  eye;  and,  while 
additional  unfocused  light  renders  accu- 
rate vision  slightly  more  difficult  and 
tiresome,  it  does  not  prevent  it.  E.  Jack- 
son (Jour,  of  Amer.  Med.  Assoc,  Sept.  1, 
'94). 

Irregular  astigmatism  may  be  due  to 
irregularity  of  the  surface  of  the  cornea, 
as  from  abrasion  or  superficial  ulceration. 

Irregularity  of  the  corneal  surfaces  and 
of  the  layer  of  mucus  covering  the  cor- 


nea, which  acts  as  a  portion  of  the  cornea 
in  the  refraction  of  light,  may  be  caused 
by  partial  closure  of  the  lids  with  press- 
ure of  the  lid-margins  upon  the  cornea, 
— that  coiistrietion  of  the  lids  which  ia 
designated   in   French   clignement.     The 
lid-margin  resembles,  somewhat,  the  rub- 
ber scrapers  used  for  cleaning  windows, 
and  constriction  of  the  lids  causes  this 
prominent  margin  to  make  a  groove  on 
the    cornea.      Brief    constriction    merely 
displaces  the  viscid  covering  of  the  cor- 
nea,  and   irregular   astigmatism   due   to 
it  disappears  with  a  single  sweep  of  the 
lids  in  winking.     Prolonged  constriction 
causes  a  groove  in  the  corneal  substance, 
the  effects  of  which  are  rendered  more 
evident  by  winking,  and  which  is  quite 
slowly  effaced.     George  J.  Bull    (Trans. 
Eighth  Inter.  Oph.  Cong.,  p.  107). 
General  bulging  of  the  cornea  is  com- 
monly not  uniform  and  gives  rise  to 
irregular  astigmatism,  the  common  form 
being  conical  cornea;  but  the  most  com- 
mon cause  is  incomplete  restoration  of 
the  corneal  tissue  to  normal  after  kera- 
titis. 

Treatment.  —  With  irregular  astigma- 
tism following  keratitis  there  is  always, 
at  first,  haziness  of  the  cornea;  and  prob- 
ably, remedies  for  corneal  opacity  im- 
prove vision  partly  by  lessening  irregular 
astigmatism. 

Conical  cornea,  if  extreme,  may  be 
greatly  improved  by  making  a  para- 
centesis at  the  apex  of  the  cone  with 
galvano-cautery  needle.  In  one  ease 
vision  improved  from  ■'/.„o  to  '"/^  with 
lenses.  R.  D.  Gibson  (Trans.,  Section  on 
Oph.,  Amer.  Med.  Assoc,  '92). 

In  a  few  cases  dilatation  of  the  pupil 
may  improve  vision  by  admitting  light 
through  a  better  portion  of  the  cornea 
or  crystalline  lens.  Iridectomy  is  appli- 
cable in  some  cases  for  the  same  purpose. 
Contraction  of  the  pupil  often  makes 
vision  better  by  lessening  the  areas  of 
diffusion.  Solutions  of  pilocarpine,  1  to 
500,  or  eserine,  1  to  2000,  may  be  in- 
stilled for  this  purpose.    Stenopaic  spec- 


528 


ASTIGMATISM.     REGULAR.     SYMPTOMS. 


tacles  improve  vision,  but  interfere  too 
much  with  the  field  of  vision  to  be  of 
much  practical  value.  Hyperboloid  lenses 
have  been  used  for  conical  cornea,  but 
rarely  vpith  enough  advantage  for  the 
patient  to  continue  their  use.  For  the 
mass  of  cases  the  correction  of  regular 
astigmatism  commonly  associated  with 
the  irregular,  and  the  tise  of  spherical 
lenses  that  will  prevent  the  straining  of 
accommodation,  is  the  only  available 
optical  treatment. 

Regular  Astigmatism. 

Definition. — It  is  the  astigmatism  that 
can  be  corrected  by  a  cylindrical  lens. 

Symptoms. — It  causes  the  blurring  of 
some  or  all  lines  looked  at.  The  eye  is 
able  to  see  with  perfect  clearness  only 
the  lines  running  in  one  direction  at  any 
one  time,  although  by  changing  its  ac- 
commodation it  may  be  able  to  see 
clearly  lines  running  at  right  angles  to 
the  first.  These  two  directions  in  which 
lines  may  be  seen  clearly,  the  "principal 
meridians,"  may  be  perceived  by  the 
patient,  although  usually  they  are  only 
recognized  when  the  eyes  are  carefully 
tested.  A  certain  adjustment  of  the 
power  of  accommodation  renders  lines 
eqxially  blurred  in  all  directions.  Astig- 
matism may  thus  cause  imperfect  vision; 
but  very  often  the  imperfection  has 
never  been  noticed  by  the  patient.  Gen- 
erally some  form  of  eye-strain,  from  the 
effort  to  focus  clearly  the  lines  running 
in  the  different  directions  which  all  ob- 
jects present,  or  to  recognize  from  im- 
perfect retinal  images  the  real  form  of 
an  object,  gives  rise  to  the  symptoms 
complained  of.  These  are  weakness  of 
the  eyes,  headache,  pain  in  the  eyes  on 
use,  inability  to  use  them  long,  excess- 
ive lacrymation,  photophobia,  nervous- 
ness, twitching  of  the  eyelids,  and  even 
more  serious  nerve  disease. 

Astigmatism    usually    co-exists    with 


hyperopia  and  myopia,  and  a  portion  of 
the  symptoms  may  be  due  to  one  of 
these. 

In  the  majority  of  cases  with  low  de- 
grees of  hyperopia  it  is  sufficient  to  cor- 
rect the  astigmatism,  and  the  correction 
of  astigmatism  removes  tlie  troublesome 
symptoms  that  were  assumed  to  depend 
on  muscular  insufficiency.  D.  B.  St. 
John  Roosa  {Ophthal.  Review,  Oct.,  '91; 
Annals  of  Oph.  and  Otol.,  '92). 

The  correction  of  astigmatism  alone 
many  times  may  give  marked  relief,  but 
it  is  better  to  give  full  correcting  glasses 
so  that  the  refraction  of  the  dioptric 
system  including  the  glasses  show  ap- 
proximate emmetropia.  S.  D.  Eisley 
(Annals  of  Oph.  and  Otol.,  July,  '92). 

The  eye-strain  caused  by  astigmatism 
is  probably  a  very  important  factor  in 
the  development  of  myopia. 

Among  2000  eyes  9  per  cent,  were 
simply  hyperopie,  but  only  Vs  of  1  per 
cent,  showed  simple  myopia.  In  the 
other  myopic  eyes  there  was  also  astig- 
matism. F.  W.  Marlow  (N.  Y.  Med. 
Jour.,  July,  '95). 

The  correction  of  errors  of  refraction, 
particularly  astigmatism,  has  greatly 
decreased  the  prevalence  of  myopia,  par- 
ticularly of  high  myopia.  In  Philadel- 
phia in  the  last  twenty  years  the  per- 
centage of  eyes  requiring  myopic  correc- 
tions is  diminished  from  25.4  to  15.2  per 
cent.  S.  D.  Risley  (Trans.  Amer.  Oph. 
Soc.,  vol.  vii,  p.  168). 

Among  809  patients,  about  70  per  cent, 
of  whom  had  astigmatism,  there  were 
60  per  cent,  suffering  from  headache,  20 
per  cent,  aching  and  pain  in  the  eyeballs, 
11  per  cent,  twitching  or  spasm  of  the 
lids,  and  11  per  cent,  had  inflammatory 
symptoms.  H.  Bert  Ellis  (Trans.,  Sec- 
tion on  Oph.,  Amer.  Med.  Assoc,  '95). 

Among  4000  eases  of  ocular  headaches, 
73  per  cent,  had  astigmatism.  Patients 
with  high  degrees  of  astigmatism  are  apt 
to  go  through  life  without  complaining 
of  eye-strain,  while  a  larger  number  of 
persons  suffer  who  have  only  the  lowest 
degrees  of  astigmatism.  This  may  be 
partly  because  low  degrees  of  astigma- 
tism are  more  common  than  the   high 


ASTIGMATISM.     REGULAR.     ETIOLOGY. 


629 


degrees;  and  probably,  also,  because 
those  with  high  astigmatism  early  learn 
to  save  their  eyes,  while  persons  wlio 
are  able  to  see  perfectly  use  and  abuse 
their  eyes  more  freely.  W.  F.  Mitten- 
dorf  (Trans.  Amer.  Oph.  Soc.,  '95). 

In  recent  examination  of  personal  case- 
book it  was  noted  that  a  large  number 
of  cases  that  had  been  examined  a  few 
years  ago  recently  on  re-examination 
showed  marked  changes  in  the  astigma- 
tism. In  some  cases  a  change  from  em- 
metropia  to  myopic  astigmatism  had  oc- 
curred, others  of  gradually  increasing 
myopic  astigmatism,  and  still  a  third 
class  in  which  there  had  been  an  in- 
crease in  the  hypermetropic  astigmatism. 
Hotz   (Phila.  Med.  Jour.,  July   16,  '98). 

Many  observers  believe  that  astigma- 
tism against  the  rule,  or  astigmatism 
with  the  meridian  placed  obliquely, 
causes  more  annoyance  than  astigma- 
tism of  the  usual  form,  in  which  the 
meridian  of  greatest  refraction  is  ver- 
tical. This  latter  may  be  due  to  the 
fact  that  the  astigmatic  eye  can  see 
perfectly  only  the  lines  that  run  in  the 
direction  of  one  of  its  principal  merid- 
ians, and  that  most  of  the  lines  which 
we  wish  to  distinguish  are  either  vertical 
or  horizontal. 

The  eye  Avith  oblique  astigmatism  sees 
vertical  and  horizontal  lines  rotated,  and 
for  the  two  eyes  to  work  together  in 
binocular  vision  this  rotation  of  the 
images  must  be  compensated  by  rotation 
of  the  eyeball  through  symmetrical  ac- 
tion of  the  oblique  muscles.  Such  an 
action  may  cause  symptoms  of  eye-strain. 
G.  C.  Savage  (Oph.  Record,  July,  '91). 

In  any  given  cases  of  astigmatism  lines 
perpendicular  to  each  other  have  their 
images  rotated  in  opposite  directions.  It 
is,  therefore,  impossible  by  rotation  of 
the  eyeball  to  make  all  the  lines  of  the 
image  in  one  eye  coiTespond  to  the  lines 
of  the  image  in  the  other.  Compensatory 
rotation  of  the  eye  is,  therefore,  only 
necessary  when  the  lines  running  in 
some  one  direction  are  decidedly  pre- 
dominant   over    lines    running    in    other 

1- 


directions.     H.   Wilson    (Arch,   of   Oph., 
July,  '94). 
Uncorrected  astigmatism  has  been  re- 
garded  as  interfering  with   the    use   of 
various  optical  instruments. 

A  careful  consideration  of  the  optical 
theory  of  the  microscope  shows  that,  on 
account  of  the  "penetrating  power"  of 
that  instrument,   astigmatism   interferes 
but  little  with  its  use.     Only  when  the 
astigmatism  is  of  high  degree  and  a  low 
power   of  microscope   is   employed   is  it 
necessary  to  consider  it  at  all,  or  resort 
to    correcting    lenses.      With    the    high 
powers  of  the  microscope  even  the  high 
grades   of  astigmatism   cause  no  distor- 
tion or  blurring  of  the  image.    Woodruff 
(Jour.  Amer.  Med.  Assoc,  Nov.  24,  '94). 
Etiology.  —  Astigmatism  is  caused  by 
a  lack  of  symmetry  in  the  curvature  of 
the  refracting  surfaces  of  the  cornea  or 
crystalline  lens,  or  an  oblique  position 
of  such  surfaces  with  reference  to  the 
visual  line.     The  statement  still  some- 
times made,  that  obliquity  or  distortion 
of  the  retina  is  capable  of  causing  astig- 
matism,  merely  betrays   the  ignorance, 
of  him  who  makes  it,  of  the  nature  of 
the  defect.     Astigmatism  caused  by  the 
cornea  may  be  partly  or  wholly  corrected 
by  an  opposite  astigmatism  caused  by 
the  crystalline  lens.    The  wide  use  of  the 
keratometer  (ophthalmometer)  of  Javal 
has  furnished  extended  statistics  regard- 
ing corneal  astigmatism,  which,  by  com- 
parison with  the  total  astigmatism  of  the 
eye,  also  indicates  the  astigmatism  due 
to  the  crystalline  lens. 

Examination  of  500  eyes  with  the 
ophthalmometer  showed  that  in  6  per 
cent,  of  all  cases  the  corneal  astigma- 
tism corresponded  with  the  total  astig- 
matism both  as  to  amount  and  as  to  the 
direction  of  the  principal  meridians.  In 
16.6  per  cent,  additional  the  amount  of 
corneal  astigmatism  exactly  equals  the 
total,  and  in  41.6  per  cent,  the  difference 
equals  0.50  dioptre  or  less.  Of  the  77.4 
per  cent,  in  Avhich  corneal  astigmatism 
does  not  correspond  with  the  total,  the 
34 


530 


ASTIGMATISM.    REGULAR.     ETIOLOGY. 


former  is  in  excess  in  62  per  cent,  and 
tlie  latter  in  15.4  per  cent.  In  34.6  per 
cent,  the  instrument  indicates  the  direc- 
tion of  the  total  astigmatism.  E.  Jack- 
son (Annals  of  Oph.  and  Otol.,  Oct.,  '94). 

In  150  eyes  affected  with  astigmatism 
the  amount  measured  by  the  ophthal- 
mometer was  greater  by  0.50  dioptre,  on 
an  average,  than  that  found  subjectively 
by  glasses,  during  paralysis  of  the  ac- 
commodation by  atropine  or  scopola- 
mine. Andogsky  and  Dolganoff  (Ann. 
d'Ocul.,  Nov.,  '94). 

Yielding  of  the  sclerotic  to  intra-ocular 
pressure  does  not  always  occur  at  the 
posterior  hole  of  the  eye.  In  most  cases 
of  astigmatism  there  is  evidence  of  this 
yielding  at  some  portion  of  the  globe, 
and  the  corneal  astigmatism  is  secondary 
to  this.  Where  the  astigmatism  is  very 
high,  the  yielding  of  the  sclerotic  is 
chiefly  lateral  and  localized.  And,  in 
cases  of  conical  astigmatism  in  A\hieh 
the  surface  of  the  cornea  is  distorted  so 
as  to  approach  the  surface  of  a  cone  with 
its  apex  to  one  side,  the  staphyloma  is 
to  be  found  in  the  neighborhood  of  the 
cornea.  R.  D.  Batten  (Oph.  Review, 
Jan.,  '97). 

Measurements  of  4270  eyes   with   the 
ophthalmometer  show  that,  on  the  aver- 
age, the  refraction  of  the  vertical  merid- 
ian is  about  0.78  dioptre  greater  than  the 
horizontal,  and  that  Vs  of  all  eyes  show 
corneal  astigmatism  of  betAveen  0.25  and 
1.25  dioptres.    Astigmatism  of  high  degree 
is  apt  to  be  associated  with  other  abnor- 
malities, is  unequal  in  the  two  eyes,  and 
has  its  meridians  obliquely  placed.    There 
is,  also,  a  marked  tendency  to  heredity 
of  the   corneal    curvature   and   astigma- 
tism.    A  Steiger   (Arch,  of  Oph.,  p.  254, 
'97). 
The  direction  of  the  principal  merid- 
ians of  astigmatism  have  been  frequently 
studied  in  the  hope  of  throwing  light  on 
the  etiology  of  the  defect. 

In  1000  cases  of  binocular  astigmatism 
the  meridian  of  greatest  curvature  was 
vertical  in  60  per  cent,  and  symmetrical 
in  the  two  eyes  in  84  per  cent.,  while,  if 
differences  of  5  or  10  degrees  in  direc- 
tion had  been  disregarded,  the  propor- 
tion of  cases  of  approximate  symmetry 


would  be  considerably  higher.    H.  Knapp 
(Trans,  of  Amer.  Oph.  Soc,  '92). 

In  2500  cases  the  direction  of  the  prin- 
cipal   meridians    were    found:     symmet- 
rical in  1307  cases;   asymmetrical  in  458; 
heteronymous — that  is,  one  meridian  at 
zero  and  a  corresponding  meridian  of  the 
other  eye  at  90  degrees — in   173   cases; 
and  homonymous — that  is,  with  the  prin- 
cipal meridians  parallel,  but  neither  ver- 
tical nor  horizontal — in  41  cases.    In  the 
cases    of    symmetrical    astigmatism    the 
meridian     of     greatest     curvature     was 
found   vertical  in  57  per  cent.;     within 
15   degrees   of  vertical   in  20  per   cent.; 
horizontal  in  12  per  cent.;    and  within 
15  degrees  of  horizontal  in  4  per  cent. 
S.  D.  Risley  and  J.  Thorington   (Trans, 
of  Sec.  on  Oph,,  Amer.  Med.  Assoc,  '95). 
Extensive  wounds  or  incisions  of  the 
cornea  give  rise  to  permanent  change  in 
the  corneal  curvature  and  astigmatism. 
This  is  most  noticeable  after  cataract  ex- 
traction.    The  astigmatism  is  highest  a 
few  days  after  the  corneal  wound  has 
closed,  and  from  then  on  slowly  dimin- 
ishes until  usually  within  three  months, 
but  sometimes  later,  it  becomes  station- 
ary.    The  changes  of  corneal  curvature 
are   flattening    of   the    cornea    at   right 
angles    to    the    incision,    and    increased 
curvature  in  the   direction  of  the  line 
joining  the  ends  of  the  incision. 

This  is  the  natural  result  of  dimin- 
ished resistance  along  the  line  of  the  in- 
cision, allowing  cornea  to  give  before  the 
intra-ocular  pressure  and  bulge  at  this 
point.  E.  Jackson  (Trans.  Pan-Amer. 
Congress,  vol.  ii,  p.  1430). 

After  operation  the  astigmatism  dimin- 
ishes by  the  increasing  approximation 
of  both  meridians  to  their  curvature 
before  operation.  With  complicated 
wounds  the  astigmatism  is  always 
greater,  and  the  decrease  from  the  origi- 
nal amount  is  less  than  in  cases  of 
normal  healing.  The  chief  causes  of  trau- 
matic astigmatism  are  the  intra-ocular 
pressure  and  the  tonic  contracture  of  the 
extrinsic  ocular  muscles.  W.  Dolganoff 
(Arch,  of  Oph.,  p.  250,  '97). 
Case   in    which    a   marked    temporary 


ASTIGMATISM.    REGULAR.    DIAGNOSIS.    TREATMENT. 


531 


change  in  the  astigmatism  had  been  pro- 
duced by  pressure  of  a  chalazion.  Nor- 
ton (Phila.  Med.  Jour.,  July  16,  '98). 

Belief  that  cocaine  has  the  effect  of 
producing  transient  astigmatism.  Grigg 
(Phila.  Med,  Jour.,  July  10,  '98). 

Attention  called  to  the  temporary  as- 
tigmatism, often  considerable  in  amount, 
that  accompanies  blepharitis  and  is  due 
to     lid-pressure.       Wurdemann      (Phila. 
Med.  Jour.,  July  16,  '98). 
Diagnosis.  —  Astigmatism  is  detected 
and  measured  by  all  of  the  various  meth- 
ods of  determining  the  refraction  of  the 
eye,  and  should  be  sought  by  more  than 
one  method  in  any  given  case.    The  chief 
reliance  is  to  be  placed  on  the  keratom- 
eter   (ophthalmometer),   skiascopy,  and 
the  test-lenses. 

Tlie  keratometer  measures  only  the 
corneal  astigmatism,  Avhich  commonly 
predominates  and  approximately  corre- 
sponds to  the  total  astigmatism.  Its 
value  is  mainly  that  it  makes  an  impor- 
tant suggestion  as  to  the  presence,  de- 
gree, and  direction  of  the  astigmatism, 
which,  when  followed  up  by  other  meth- 
ods of  measurement,  effects  a  saving  of 
time.  Skiascopy  measures  the  total  as- 
tigmatism of  the  eye,  usually  with  the 
greatest  accuracy  of  any  method.  Com- 
mittee on  Objective  Tests  for  Ametropia 
(Trans.,  Section  on  Oph.,  Amer.  Med. 
Assoc,  '94). 

Latent  astigmatism  may,  in  many 
cases,  be  made  manifest  and  mea.sured 
without  a  cycloplegic,  by  giving  lenses, 
which  correct  the  manifest  only,  to  be 
worn  a  day  or  two,  when  additional 
astigmatism  will  be  manifest,  which  is 
also  to  be  corrected;  and  so  on,  until 
the  latent  trouble  is  unmasked.  H.  M. 
Starkey  (Trans.  See.  on  Oph.,  Amer. 
Med.  Assoc.,  '95). 

In  determining  astigmatism  make  the 
meridian  of  least  refraction  slightly  my- 
opic, and  determine  the  astigmatism  by 
concave  cylindrical  glasses,  afterward 
ascertaining  the  spherical  glasses.  In 
other  word.s,  make  the  astigmatism  my- 
opic, and  then  measure  it  in  the  remote 
zone,  generally  by  distance  tests.  George 
J.  Bull  (Oph.  Review,  p.  27.5,  '95). 


Whether  astigmatism  is  even  partially 
corrected  by  unequal  contraction  of  dif- 
ferent parts  of  the  ciliary  muscle,  or  is 
not  so  corrected,  must  still  be  regarded 
as  uncertain. 

In  two  medical  students  with  normal 
vision  the  vision  remained  good  with 
strong  cylinders,  but  after  the  use  of 
atropine  no  cylindrical  lens  whatever 
could  be  overcome.  To  prevent  error  the 
eyelids  were  held  so  that  they  could  not 
press  on  the  globe.  From  this  experi- 
ment it  is  inferred  that  the  power  of  ac- 
commodation enables  the  eye  to  over- 
come astigmatism  either  by  change  in 
the  curvature  of-  the  crystalline  lens  or 
by  tilting  it.  Guilloz  (Arch.  d'Oph.,  vol. 
xiii,  p.  676). 

When  the  retina  lies  half-way  between 
the  anterior  and  posterior  focal  lines,  it 
receives  small  circles  of  difTusion,  which 
allow  lines  running  in  different  direc- 
tions to  be  seen  with  equal  clearness. 
Placing  before  one  eye  fine  print,  and  be- 
fore the  other  cross-threads,  when  the 
fine  print  was  read  the  threads  were  only 
seen  clearly  if  accurately  placed  at  the 
point  for  which  the  eyes  were  focused. 
When  reading  with  eyes  made  astig- 
matic, it  was  found  that  the  astigmatism 
was  corrected  by  bringing  these  smaller 
circles  of  diffusion  on  the  retina.  By 
extremely  fine  threads  placed  to  cor- 
respond with  the  meridians  of  astigma- 
tism it  was  demonstrated  that  under 
the  most  favorable  circumstances  no 
compensatory  action  in  the  ciliary 
muscle  was  shown.  C.  Hess  (von 
Grate's  Archiv,  Part  II,  "96). 

Treatment. — For  regular  astigmatism 
the  usual  remedy  is  the  wearing  of  cylin- 
drical lenses,  which  should  correct  the 
full  amount  of  the  astigmatism  and  be 
worn  constantly.  Any  case  of  astigma- 
tism may  be  thus  corrected  by  a  convex 
cylindrical  lens  with  its  axis  ^  placed 
parallel  to  the  meridian  of  greatest  cur- 
vature, or  by  a  concave  cylindrical  lens 
with  its  axis  placed  perpendicular  to 
this,  or  by  two  lenses  of  proper  strengths 
with  their  axes  respectively  parallel  to 


532 


ASTIGMATISM. 


ATHETOSIS. 


the  two  meridians.  As  may  readily  be 
demonstrated  mathematically  or  by 
trial,  the  optical  effect  of  any  possible 
combination  of  cylindrical  lenses  may 
be  produced  by  the  proper  single  cylin- 
drical lens  combined  with  the  proper 
spherical  lens. 

Javal  has  pointed  out  that  sometimes 
the  meridians  of  greatest  curvature  are 
not  perpendicular  to  each  other.  Two 
cases  are  reported,  corrected  by  crossed 
cylinders  with  their  bases  obliquely 
placed  parallel  to  these  oblique  merid- 
ians.   Eoure  (Arch.  d'Oph.,  Apr.,  '96). 

The  fact  that  corneal  incisions  change 
the  corneal  curvature  has  suggested  their 
employment  for  the  correction  of  astig- 
matism. 

Ten  observations  show  the  possible 
diminution  and  relative  curability  of 
astigmatism  by  incisions  in  the  cornea. 
The  change  from  one  incision  was  about 
1  dioptre.  When  the  incision  is  not 
carried  through  the  cornea  so  as  to  per- 
mit the  escape  of  the  aqueous  humor, 
contrary  to  what  takes  place  after  cata- 
ract extraction,  iridectomy,  etc.,  there  is 
an  increase  of  the  corneal  curvature  in 
the  direction  of  the  incision.  Lucciola 
<Arch.  d'Oph.,  Oct.,  '96). 

A  case  is  reported  by  Dr.  Bull,  of 
Paris,  in  which  a  complete  tenotomy  of 
the  external  rectus  for  the  correction 
of  an  exophoria  produced  the  unexpected 
result  of  curing  a  progressive  myopic 
astigmatism  against  the  rule,  or,  as  Dr. 
Bull  prefers  to  call  it,  "inverse"  astig- 
matism, where  the  greatest  curvature  of 
the  cornea  is  in  the  horizontal  meridian. 
If  this  astigmatism  had  been  measured 
by  the  retinoscope  alone,  the  relief  ob- 
tained might  reasonably  have  been  as- 
cribed to  relaxation  of  an  irregular 
spasm  of  the  ciliary  muscle,  particularly 
as  the  degree  of  astigmatism  appeared 
to  be  inconstant,  but  the  ophthalmom- 
eter showed  that  the  astigmatism  was 
produced  by  the  difference  in  the  curva- 
tures of  the  vertical  and  horizontal 
meridians  of  the  cornea.  Three  days 
after  the  operation  the  ophthalmometer 
showed  that  this  difference  in  the  curva-   ' 


tures  of  the  two  meridians  of  the  cornea 
had  disappeared,  while  at  the  same  tune 
the  subjective  astigmatism  had  gone  and 
the  vision  of  the  eye  had  risen  to 
normal.  Because  of  this  record  the  as- 
tigmatism and  poor  vision  before  the 
operation  cannot  be  ascribed  to  hysteria 
any  more  than  to  ciliary  spasm,  and 
the  conclusion  is  necessary  that  some 
corneas  have  their  form  easily  influ 
enced  by  the  tension  of  the  external 
ocular  muscles.  A  corollary  to  this  is 
that  when  a  surgeon  has  to  deal  with 
such  a  cornea  he  may  be  able,  not  only 
to  cure  an  astigmatism  by  an  operation 
on  these  muscles,  but  also  to  produce 
an  astigmatism  or  increase  one  already 
present  by  an  incautious  interference. 

Dr.  Bull's  observation  opens  the  way 
to  investigations  which  may  prove  of 
essential  service  in  some  obscure  con- 
ditions. If  an  etiological  connection 
between  progressive  astigmatism,  or  the 
position  and  relative  tension  of  the 
ocular  muscles,  and  glaucoma  can  finally 
be  demonstrated,  he  will  be  entitled  to 
the  credit  at  least  of  having  made  the 
first  suggestion,  and  it  is  to  be  hoped 
that  the  results  of  the  investigations 
he  proposes  to  make  may  be  as  brilliant 
as  the  result  he  obtained  from  the 
operation  he  has  described.  At  the  same 
time  it  is  to  be  hoped  that  this  opera- 
tion will  be  tried  conservatively  and  its 
limitations  clearly  defined  before  it  is 
brought  into  general  use,  for  "such  an 
operation  for  the  cure  of  astigmatism, 
should  be  undertaken  only  in  very  ex- 
ceptional cases,"  while  the  damage 
which  may  be  done  by  incautious  or 
unskilled  interference  with  the  muscles 
of  the  eye  has  been  demonstrated  to 
be  very  great.  Editorial  (New  York 
Medical  Journal,  Feb.  7,  1903). 

Edward  Jackson, 


ATHETOSIS.  — (Lat.).  From  Gr., 
aderoi  :  a,  priv.,  and  ridh'ai^  to  bring 
into  position. 

Definition. — A  nervous  disorder  char- 
acterized by  involuntary  movements  of 
the  fingers  and  toes,  apparently  of  a  uni- 


ATHETOSIS.    ETIOLOGY. 


533 


form  and  systematic  character.  It  may 
be  partial,  affecting  a  limited  portion  of 
the  body,  or  general,  the  movements  be- 
ing wide-spread.  The  latter  form  is  also 
termed  "idiopathic." 

Symptoms. — The  striking  peculiarity 
of  this  disease,  first  described  by  W.  A. 
Hammond,  of  New  York,  is  that  the 
parts  concerned  in  the  spasmodic  move- 
ments, usually  the  fingers  and  toes  of  the 
one  side,  are  constantly  moving,  though 
to  a  limited  degree,  during  sleep,  inde- 
pendently of  the  patient's  will.  The 
fingers  are  alternately  flexed  and  ex- 
tended with  varying  degrees  of  adduc- 
tion and  abduction,  and  with  a  tendency 
to  distortion.  The  movements  are  not 
always  limited  to  the  fingers  and  toes, 
however,  the  muscles  of  the  arm  and  leg, 
and  sometimes  those  of  the  face,  taking 
part  in  the  spasmodic  seizures  in  a  small 
proportion  of  cases.  In  these  cases  the 
arm  is  swung  to  and  fro  in  regular 
rhythmic  movements  and  the  alternate 
contractions  and  relaxations  of  the  facial 
muscles  give  rise  to  grimaces.  These 
movements  are  often  preceded,  or  accom- 
panied, by  other  symptoms  of  cerebral 
disease,  especially  epileptic  seizures  and 
impairment  of  the  intellect.  This  occxirs 
most  frequently  in  middle-aged  men  of 
intemperate  habits.  Hemiansesthesia  and 
other  perversions  of  sensation  are  often 
present. 

The  idiopathic  form  is  usually  bilat- 
eral; the  gait  is  characteristic  in  the  ma- 
jority of  cases;  they  seem  constantly  to 
be  on  the  point  of  falling,  while  violent 
contortions  of  the  extremities  occur  si- 
multaneously. 

Case  in  whieh,  at  every  attempt  at 
motion,  hand,  fingers,  legs,  and  feet 
slowly  flexed.  R.  M.  Phelps  (Inter.  Med. 
Mag.,  Feb.,  '95). 

Etiology.  —  The  etiology  of  this  af- 


fection is  obscure.  Falls,  compression  of 
the  head  during  birth,  cerebral  haemor- 
rhage, fright,  alcoholism,  syphilis,  and 
cerebral  growths  are  among  the  most 
prominent  factors.  Heredity  has  been 
clearly  ascertained  in  a  niimber  of  cases. 

Case  of  athetosis  affecting  principally 
the  left  hand  of  a  woman  aged  43  years. 
The  disease  commenced  in  childhood, 
after  a  fall,  which  caused  no  other  dis- 
turbance. Von  Bonsdorff  (Finska  Laka- 
resilUskapets  Handlingar,  B.  30,  H.  3). 

Case  of  acute  hemiparesis  with  hemi- 
athetotie  movements,  following  excessive 
use  of  the  arms  for  two  days  and  two 
nights  in  a  handicraft.  Lowenthal 
(Deutsche  med.  Woch.,  Apr.  11,  '89). 

Three  cases  of  hemiathetosis  in  a 
young  child,  and  of  double  athetosis  in 
a  woman  and  a  young  boy.  Archibald 
Church  (Rev.  of  Insan.  and  Xerv.  Dis., 
Mar.,  '92). 

Case  of  bilateral  athetosis  in  a  man 
of  43  years,  formerly  insane  and  addicted 
to  alcohol,  in  whom  the  disease  devel- 
oped gradually,  beginning  at  the  ex- 
tremities, and  later  on  involving  the 
neck,  the  face,  and  finally  accompanied 
by  complete  aphasia.  Parsons  Norbury 
(Med.  Fortnightly,  Apr.  15,  '92). 

[This  case  is  interesting,  as  it  shows 
that  double  athetosis  is  not  always  ac- 
companied by  imbecility,  and  that  it 
does  not  always  date  from  early  infancy. 
BOUBNEVILLE  and  SOLLIER,  Assoc.  Eds., 
Annual,  '93.] 

Case  of  athetosis  which,  like  so  many 
cases  of  the  kind,  developed  after  an 
apoplectic  attack  when  the  patient  was 
a  child  (3  years  old),  and  had  persisted 
now  for  twenty-three  years.  The  move- 
ments do  not  stop  altogether  during 
sleep.  Report  of  Professor  Baelz 
(Corres.  Ed.  of  the  Annual,  Tokio, 
Japan) . 

Case  of  hemiathetosis  in  a  young  child, 
following  measles,  supporting  the  per- 
sonal opinion,  given  in  1887,  that  the 
disease  originates  in  children  in  infec- 
tious diseases,  either  of  unknown  or  of 
well-known  origin,  such  as  the  eruptive 
fevers  of  infancy.  Roberto  Massalongo 
(Riforma  Med.,  Sept.  3,  '92). 


534 


ATHETOSIS.     PATHOLOGY. 


Double  athetosis  following  birth  or 
occurring  in  early  infancy  belongs  to  the 
group  of  infantile  cerebral  diplegias. 
The  common  feature  of  these  affections 
is  premature  birth  or  difficult  labor,  and 
the  common  lesion  is  arrested  develop- 
ment of  the  pyramid.  Lannois  (Le  Bull. 
M6d.,  Apr.  19,  '93). 

Typical  athetotic  movements  after 
sudden  fright  in  a  child.  Rauzier  and 
Cazalis  (Le  Bull.  Med.,  Nov.  28,  '94). 

Cases  in  mother  and  child.  Symptoms 
exactly  alike.  Oppenheim  (Berliner  klin. 
Woeh.,  Aug.  26,  '95). 

Double  athetosis  in  a  syphilitic 
woman.  Father  epileptic.  Erandeis  (Le 
Bull.  Med.,  Sept.  1,  '95). 

Case  of  functional  athetosis,  appar- 
ently of  traumatic  origin.  The  patient — 
a  girl,  aged  9  years,  with  a  negative 
family  history — had  fallen  from  the  rings 
while  exercising  in  a  turning-school,  but 
apparently  suffered  no  bad  effects  from 
the  fall.  Inattention,  carelessness,  and 
lack  of  desire  for  study  first  appeared, 
followed  by  great  difficulty  in  holding 
any  object  in  her  left  hand.  There  were 
also  certain  peculiar,  involuntary  move- 
ments of  the  left  upper  extremity,  more 
marked  in  the  hands  and  fingers,  which 
were  always  brought  on  by  attempts  at 
voluntary  movements,  and  which  were 
never  present  during  sleep.  Left  foot 
dragged  slightly  when  walking.  Pupil- 
lary and  patellar  reflexes  were  normal; 
no  impairment  of  sensation;  no  contrac- 
tion or  atrophies;  muscular  power  in 
left  hand  and  arm  did  not  seem  impaired, 
though  there  may  possibly  have  been  a 
slight  degree  of  paresis,  and  muscular 
development  was  normal.  Heart-sounds 
were  normal.  Examination  of  eyes  nega- 
tive. Iron  and  arsenic  administered.  In 
five  weeks  the  athetoid  movements  had 
disappeared.  E.  G.  Thomas  (Medicine, 
Aug.,  '97). 
Pathology. — Athetosis  is  closely  allied 
to  posthemiiDlegic  chorea,  and  is  usually 
due  to  some  lesion  of  the  optic  thala- 
mus: a  thrombus  or  tumor  and  particu- 
larly to  embolism. 

Case  of  athetosis,  or  choreic  spasm  of 
the  right  side  of  the  body,  due  to  a 
tumor   of   the   left   optic   thalamus   and 


adjacent  internal  capsule.  All  the  cases 
of  athetosis  and  chorea  following  hemi- 
plegia are  due  to  lesions  in  this  vicinity. 
Seguin  (Boston  Med.  and  Surg.  Jour., 
July  17,  '90). 

Autopsy  of  case  upon  ■which  W.  A. 
Hammond's  description  of  the  disorder 
was  based.  The  portion  Involved  in  the 
lesion  had  consisted  of  fibrous  connect- 
ive tissue.  Topographically,  the  lesion 
was  a  lengthy  one  in  the  antero-posterior 
direction,  parallel  in  its  short  axis  with 
the  internal  capsule.  Its  posterior  end 
had  invaded  the  stratum  zonale  of  the 
thalamus  on  its  posterior  third  and  the 
posterior  half  of  the  internal  capsule. 
In  its  anterior  extension  it  had  crossed 
the  capsule,  invading  the  posterior  third 
of  the  outer  lenticulus.  The  author 
called  attention  to  the  fact  that  this 
case  was  further  evidence  of  his  theory 
that  athetosis  was  caused  by  irritation 
of  the  thalamus,  the  striatum,  or  the 
cortex,  and  not  by  a  lesion  of  the  motor 
tract.  G.  M.  Hammond  (Boston  Med. 
and  Surg.  Jour.,  July  17,  '90). 

In  those  cases  of  athetosis  in  which  a 
lesion  has  been  found,  if  it  has  been  lo- 
cated in  the  posterior  limb  of  the  inter- 
nal capsule  or  in  the  adjacent  portion  of 
the  optic  thalamus  these  are  the  sites 
of  sensory  organs.  These  lesions  could 
not  produce  the  symptoms  of  athetosis 
by  direct  irritation  of  the  neighboring 
pyramidal  tract,  for,  if  they  would,  the 
abnormal  movement  would  be  more  com- 
mon in  the  lower  or  internal  extremi- 
ties, whereas  the  reverse  of  this  is  the 
case.  Frank  Fisher  (Med.  Age,  Mar.  25, 
1900). 

Lesions  of  the  lenticular  nitcleus  have 
also  been  found,  consisting  mainly  in 
softening. 

Case  of  athetosis,  following  a  left-sided 
hemiplegia,  in  which  the  autopsy  re- 
vealed four  or  five  points  of  softening 
of  the  size  of  the  head  of  a  pin  in  the 
right  nucleus  lenticularis,  and  an  old 
hemorrhage  the  size  of  a  hazel-nut  lying 
between  the  body  of  the  nucleus  cau- 
datus  and  the  optic  thalamus,  and  in- 
volving the  knee  of  the  internal  capsule 
of  the  right  side.  Sabrazes  (Jour,  de 
Med.  de  Bordeaux,  Oct.  6,  '89). 


ATHETOSIS.     DIAGNOSIS.     TKEATMENT. 


535 


Case,  in  a  young  girl  of  12  years,  dat- 
ing from  birth,  of  double  athetosis,  with 
autopsy.  An  absence  of  the  corpus  cal- 
losum  and  of  the  floor  of  third  ventricle 
was  observed.  The  left  temporal  lobe 
was  retracted,  and  the  lenticular  nucleus 
softened  and  completely  bare.  At  the 
extremity  of  the  lobe  there  was  an  old 
abscess;  capacity  about  one  ounce.  In 
the  right  temporal  lobe  there  was  also  a 
small  cavity,  the  seat  of  a  former  ab- 
scess. Athetosis  is  a  pathological  entity. 
Lesion  of  the  lenticular  nucleus  is  met 
with  in  the  majority  of  cases.  J.  Wright 
Putnam  (Jour,  of  Nerv.  and  Mental  Dis., 
Feb.,  '92). 

Case  proving  that  athetosis  is  not  due 
to  irritation  of  the  lenticular  nucleus, 
but  of  the  neighboring  pyramid.  It  also 
confirms  the  opinion  of  SchifF  that  the 
striated  body  exercises  no  motor  func- 
tion. Combe  (Revue  Mgd.  de  la  Suisse 
Rom.,  Oct.,  '92). 

The  motor  regions  of  the  cortex  are 
thought,  by  some  observers,  to  at  least 
be  implicated  in  the  pathological  process. 

The  lesion  of  athetosis  is  undoubtedly 
in  the  cortex  of  the  brain,  and  the  best 
success  may  be  obtained  from  galvanism 
there  and  also  to  the  head.  Eienzi  (Gaz. 
degli  Osp.,  '86). 

Four  cases  of  hemiathetosis  in  which 
the  movements  ceased  during  profound 
sleep,  but  persisted  to  a  moderate  degree 
during  light  sleep,  tending  to  indicate 
that  the  point  of  origin  of  the  move- 
ments of  athetosis  lies  in  motor  regions 
of  the  cerebral  cortex,  although  many 
autopsies  have  shown  a  lesion  of  the  an- 
terior portion  of  the  internal  capsule  in 
such  cases.  Eulenberg  (Wiener  med. 
Presse,  Feb.  24,  '89). 

There  may  be  a  lesion  of  the  cerebral 
convolutions,  with  descending  degenera- 
tion; so  that  double  athetosis  may  be 
regarded  as  a  cerebro-spinal  affection. 
The  abnormal  movements  are  caused  by 
an  irritation  of  any  portion  of  the  motor 
tract.  Massalongo  (Le  ProgrSs  Med., 
Jan.  18,  Oct.  II,  '90). 

In  fourteen  cases  of  athetosis  in  which 
autopsies  have  been  made,  foci  were 
found  seven  times  in  the  striatum,  four 
times  in  the  thalamus,  twice  in  the  pons. 


and  once  in  both  thalamus  and  striatum. 
In  three  other  cases  only  cortical  lesions 
were  reported,  but  the  possibility  of  in- 
volvement of  the  basal  ganglia  has  not 
been  excluded  in  these.  In  two  reported 
cases  of  paretic  dementia  with  athetosis 
the  lesions  were  limited  to  the  cortex; 
personal  case  in  which  there  was  intense 
atrophy  of  the  thalamus  attributed 
mainly  to  the  involuntary  movements. 
The  cortical  lesions  did  not  differ  from 
those  seen  in  many  cases  of  general 
paralysis  without  athetoid  movements. 
The  degeneration  of  the  pyramidal  tract 
was  equally  intense  above  the  motor 
decussation.  M.  Sander  (Neurol.  Cen- 
tralb..  No.  7,  '97). 

Diagnosis. — There  is  no  absolute  dif- 
ference between  athetosis  and  posthemi- 
plegic chorea.  If  the  lesion  be  acute, 
hemichorea  is  produced;  if  chronic, 
hemiathetosis.  In  chorea  the  moTC- 
ments  are  sudden  and  involuntary;  in 
athetosis  they  are  slow,  and  ordinarily 
do  not  interfere  with  voluntary  acts, 
except  to  lessen  their  rapidity.    (Eienzi.) 

Study  of  muscular  shocks  and  the 
faradic  electrical  reactions  in  a  patient 
attacked  with  complete  left  hemiathe- 
tosis, the  face  being  included.  The  mus- 
cular tonus  was  exaggerated  by  the  gal- 
vanic current.  The  form  of  athetotic 
contraction  greatly  resembles  that  of 
contracture,  whence  its  greater  impor- 
tance than  in  choreiform  movements. 
There  is  inequality  in  the  muscular 
tonus,  shown  by  faradic  reaction,  which 
arises,  doubtless,  from  the  irregular, 
spontaneous  contractions  of  the  muscles. 
Domenico  Cappozzi  (Riforma  Med.,  Aug. 
25,  '92). 

Treatment. — Although  this  disease  is 
regarded  as  incurable,  functional  cases 
have  been  reported  in  which  arsenic  and 
iron,  with  bromide  of  potassium,  have 
brought  about  satisfactory  results.  The 
galvanic  current,  the  positive  pole  being 
placed  over  the  brachial  plexus  and  the 
negative  on  the  neck,  has  been  recom- 
mended   by    Kraift-Ebing.      Hammond 


536 


ATROPINE.    PHYSIOLOGICAL  ACTION. 


has  obtained  good  results  from  nerve- 
stretching. 

Case  treated  at  first  with  potassium 
bromide,  afterward  with  arsenic,  and 
blisters  were  applied  behind  the  right  ear. 
The  movements  gradually  ceased.  The 
patient  was  quite  -well  in  three  weeks 
and  had  no  relapse.  Macaldowie  (Brain, 
July,  '88). 

Treatment  lasting  six  weeks,  and  con- 
sisting of  1  Vi  drachms  of  bromide  of 
potassium  daily,  and  the  stabile  appli- 
cation of  the  galvanic  current  of  2  mil- 
liamp6res,  the  positive  pole  on  the 
brachial  plexus,  the  negative  on  the 
neck,  brought  about  a  temporary  cure, 
which  would  probably  have  been  per- 
manent had  the  treatment  been  con- 
tinued longer.  Krafft-Ebing  (Wiener 
klin.  Woch.,  Apr.  18,  '89). 

Marked  case  in  which  three  months' 
rest  in  the  hospital,  electrical  treatment, 
and  the  administration  of  codliver-oil, 
arsenic,  and  iron  improved  affected  mus- 
cles very  much.  Strychnine  was  found 
to  increase  the  rigidity.  Since  leaving 
the  hospital,  however,  the  paralysis  and 
the  wasting  have  made  steady  progress. 
Miehell  Clarke  (Bristol  Medico-Chir. 
Jour.,  June,  '97). 

Jeeemiah  T.  Eskeidge, 

Denver. 

ATROPINE.  —  Atropine  (atropina  of 
the  U.  S.  Ph.  and  Br.  Ph.;  atropinum 
of  German  Ph.)  is  an  allvaloid  obtained 
from  the  leaves  and  roots  (bark  of  the 
root)  of  the  deadly-nightshade  {Atropa 
lelladonna,  L.).  It  occurs  in  white, 
acicnlar  crystals,  or  in  white,  amorphous 
powder  (turns  yellow  upon  exposure  to 
the  air)  of  bitter,  acrid  taste  and  decided 
alkaline  reaction;  is  soluble  in  130  parts 
of  water,  3  parts  of  alcohol,  16  parts  of 
ether,  4  parts  of  chloroform,  and  in  50 
parts  of  glycerin.  It  melts  at  239°  F. 
Atropine  forms  salts,  when  combined 
with  acids,  among  which  are  the  hydro- 
chlorate,  nitrate,  salicylate,  and  sul- 
phate;  these  salts  are  generally  used  on 


account  of  their  greater  solubility  and 
neutral  reaction. 

Atropine  and  hyoscyamine  are  prac- 
tically identical,  and  both  atropine — 
heavy  atropine — and  hyoscyamine — light 
atropine — can  be  obtained  from  either 
belladonna  or  hyoseyamus.  The  tend- 
ency, nowadays,  is  to  use  the  term 
"heavy"  atropine  in  place  of  atropine, 
and  "light"  atropine  in  place  of  hyoscy- 
amine. The  difference  between  them  is 
purely  chemical,  and  pharmacologically 
the  two  products  are  identical. 

These  discoveries  necessitate  a  consid- 
erable modification  in  the  classification 
of  the  alkaloids  originally  adopted.  The 
most  recent  views  on  the  subject  are 
expressed  in  the  following  table: — 

Belladonn.i  cont.iins Atropi 

Hvoscvamua  f  Hyosc3'amine= Atrop; 

contains     i  fj„.„i_„    f  Scopolamine Soopol, 

1.  Myoscino   ^  Hjoacyamine- Atropi 

Stramoninm  contains  /Atropine Atropi 

Daturine  \  Hyoscyamine= Atropi 

Scopolia  contains Scopolam; 

Duboisia  contains  Duboisine=IIyoscy.amine= Atropi 

This  arrangement  considerably  lightens 
our  labors,  for,  instead  of  having  half  a 
dozen  alkaloids  to  consider,  we  have  now 
only  two.  William  Murrell,  of  London 
(Med.   Brief,  Jan.,   '98). 

Atropine  is  chemically  incompatible 
with  the  alkalies,  tannin,  and  the  salts 
of  mercury;  it  is  physiologically  incom- 
patible with  morphine  (opium),  pilocar- 
pine, muscarine,  aconitine,  and  eserine 
(physostigmine). 

Dose  and  Physiological  Action. — The 
usual  dose  of  atropine  given  internally 
is  from  ^/i,o  to  ^/eo  grain.  The  maxi- 
miim  single  dose  is  ^/jo  grain.  The 
physiological  action  has  been  observed 
and  described  by  John  Harley.  If  ^/i^o 
grain  be  injected  beneath  the  skin  of 
a  healthy  adult,  there  will  be  noticed, 
after  10  to  20  minutes,  a  quickening  of 
the  pulse,  and  generally  a  small  increase 
in  volume  and  power.  This  change  will 
be  very  decided  if  the  pulse  was  pre- 
viously slow  and  feeble.  The  increase 
in  the  number  of  pulse-beats  will  gen- 
erally amount  to  20  per  minute;   it  will 


ATROPINE.    PHYSIOLOGICAL  ACTION. 


537 


take  place  suddenly,  and  attain  its  maxi- 
mum within  one  or  two  minutes.  In 
about  half  an  hoiir  a  gradual  decline 
takes  place  and  the  heart  soon  returns 
to  its  usual  state,  and  continues  to  beat 
as  quickly  and  powerfully  as  before. 
Just  as  the  pulse  rises,  a  slight  giddiness 
is  often  perceptible.  Usually  these  will 
be  the  whole  of  the  symptoms;  but,  in 
weak  and  delicate  adults,  a  feeling  of 
dryness  of  the  mouth  and  throat,  and, 
at  the  end  of  an  hour  or  two,  a  slight 
dilatation  of  the  pupil,  in  a  subdued 
light,  will  be  superadded. 

When  Vso  grain  is  used,  the  accelera- 
tion of  the  pulse  will  be  found  to  range 
between  20  and  60  beats,  the  rise  being 
attended  by  considerable  giddiness  and 
waviness  of  the  vision.  The  patient 
walks  cautiously,  and  with  an  inclina- 
tion to  iinsteadiness.  After  20  to  40 
minutes  he  will  complain,  with  some 
huskiness  of  voice,  of  great  dryness  of 
the  throat  and  mouth;  and  the  anterior 
part  of  the  tongue  or  the  whole  of  the 
dorsum,  excepting  a  wide  margin,  will 
be  found  dry,  brown,  and  rough.  The 
hard  palate  and,  in  many  persons,  the 
soft  palate  also,  will  be  perfectly  dry  and 
glazed.  There  will  be  more  or  less  som- 
nolency, and  sometimes  a  little  flushing 
of  the  face.  The  dilatation  of  the  pupils 
will  amount  to  ^/^  or  ^/g  inch. 

The  effects  of  ^/^g  grain  (a  full  me- 
dicinal dose)  are  as  follow:  After  10  or 
15  minutes  an  acceleration  of  the  pulse 
from  20  to  70  beats;  no  apparent  change 
in  volume,  but  a  decided  increase  in  the 
force  of  the  cardiac  contractions  and  of 
the  arterial  tonus;  a  general  diffusion 
of  warmth,  a  slight  throbbing  or  heav- 
ing sensation  in  the  carotids,  and  a  feel- 
ing of  pressure  imder  the  parietal  bones; 
giddiness,  heaviness,  drowsiness,  or  actual 
sleep,  with  great  tendency  to  dreamy  de- 
lirium, and,  in  women,  slight  occasional 


startings;  complete  dryness  of  the  tongue, 
roof  of  the  mouth,  and  soft  palate,  ex- 
tending more  or  less  down  the  pharynx 
and  larynx,  rendering  the  voice  husky, 
and  often  inducing  dry  cough  and  diffi- 
culty in  swallowing;  parched  lips,  occa- 
sional dryness  of  the  mucous  membranes 
of  the  nose  and  eyes,  and  increasing 
dilatation  of  the  pupils.  After  about 
two  hours  the  dryness  of  the  mouth  is 
relieved  by  the  appearance  of  a  viscid, 
acid  secretion  of  an  offensive  odor,  like 
the  sweat  of  the  feet;  the  mouth  be- 
comes foul  and  clammy,  and  a  bitter, 
coppery  taste  is  complained  of;  but  as 
moisture  returns  to  the  mouth,  the  pulse 
is  observed  to  fall,  and  it  now  rapidly 
regains  its  ordinary  rate  and  character. 
The  pupils  have  now  reached  their  max- 
imum dilatation  and  measure, — about 
^/s  inch;  but,  when  exposed  to  bright 
light,  they  will  still  contract  to  ^/i,  ^/s, 
or  even  Vs  inch,  according  to  their  orig- 
inal size.  Slight  elevation  of  surface- 
temperature  is  noticed  during  the  action 
of  the  medicine,  rarely  exceeding  1°, 
and  a  still  less  elevation  of  the  internal 
temperature  of  the  body.  No  difference 
will  be  observed  in  the  rate  of  the  res- 
piration, except  (in  nervous  women)  a 
little  emotional  excitement  on  the  sud- 
den accession  of  the  giddiness.  The 
breathing  will  be  tranquil,  the  patient 
occasionally  heaving  a  deep  sigh,  and 
still  oftener  taking  a  prolonged  yawn,  as 
he  sits  still  in  a  dull,  apathetic  or  drowsy 
condition.  After  the  pulse  has  resumed 
its  ordinary  rate,  and  the  mouth  has  be- 
come moist,  the  giddiness  and  drowsiness 
pass  off,  and  the  patient  appears  toler- 
ably lively  and  brisk  in  mind  and  body. 
But  he  will  himself  continiie  to  feel  for 
some  hours  longer  such  languor  of  body 
and  mind  as  will  render  him  disinclined 
for,  or  even  incapable  of,  active  bodily 
or  mental  exertion.     Slight  dimness  of 


538 


ATROPINE.     PHYSIOLOGICAL  ACTION. 


vision  also  remains,  and  the  patient  is 
unable  to  thread  a  needle,  or  even  to 
read. 

If  larger  doses  be  given,  there  will  be 
superadded  a  distressing  fluttering  sen- 
sation in  the  cardiac  region,  slight  de- 
lirium; exquisite  sensibility  of  hearing, 
and  frequent  illusions  of  this  sense  also; 
staggering,  or  complete  inability  to  walk; 
insomnia,  restlessness,  and  frequently 
great  nervous  agitation  of  mind  and 
body.  Nausea  and  headache  are  rare 
and  exceptional  consequences  of  the  sub- 
cutaneous use  of  atropine,  but  sometimes 
follow  when  given  by  the  stomach  in  full 
doses. 

Certain  conditions  modify  the  action 
of  atropine.  Children  are  more  tolerant 
of  the  drug  than  adults,  and  in  this 
respect  resemble  the  lower  animals;  and 
while  acceleration  of  the  pulse,  dilatation 
of  the  pupils,  and  dryness  of  the  mouth 
are  more  readily  induced  in  them,  cere- 
bro-spinal  effects — giddiness,  drowsiness, 
sensory  illusions,  and  unsteadiness  of 
gait — are  only  developed  after  a  very 
large  dose.  Pregnancy  appears  to  di- 
minish the  activity  of  atropine.  The 
weak,  and  those  of  excitable  tempera- 
ment, are  more  readily  and  powerfully 
influenced  than  the  strong.  In  renal 
disease,  when  the  secretion  of  urine  is 
diminished,  or  only  moderate  in  quan- 
tity, thfi  effects  of  atropine  are  readily 
induced  and  considerably  prolonged;  in 
persons  with  unusually  active  kidneys 
the  action  of  the  drug  is  less  pronounced. 
While  atropine  in  contact  with  caustic 
soda  and  potash  is  decomposed  in  the 
course  of  two  or  three  hours,  these  bodies 
have  no  power  of  annulling  or  even 
diminishing  the  action  of  the  alkaloid 
within  the  body.  Acids  have  no  partic- 
ular influence  on  the  action  of  atropine. 
When  administered  by  the  stomach,  the 
action   of   the   drug   is   sometimes   pro- 


longed for  two  hours,  and  then  develops 
suddenly. 

Atropine  passes  undiminished  and  un- 
changed through  the  blood,  and  the  kid- 
neys are  active  in  its  elimination  from 
the  minute  that  it  enters  the  circulation 
until  it  is  entirely  removed  from  the 
body.  After  a  full  medicinal  dose,  be- 
tween two  or  three  hours  are  required 
for  this  purpose.  The  presence  of  atro- 
pine in  the  renal  secretion  after  taking 
the  drug  may  be  demonstrated  by  drop- 
ping one  or  two  drops  of  the  urine  within 
the  eyelids  of  another  person  or  animal 
at  intervals  of  10  to  20  minutes  for  two 
or  three  hours  and  noticing  its  dilating 
action  on  the  pupils.  The  atropine  may 
be  separated  from,  the  urine  by  shaking 
the  latter  with  a  quantity  of  chloroform 
equal  to  a  sixth  of  its  bulk,  and  sepa- 
rating the  chloroform,  or  allowing  it  to 
evaporate  spontaneously.  The  remain- 
ing stain  is  dissolved  in  a  few  drops  of 
water,  and  a  drop  placed  within  the  eye- 
lids. The  Vge  grain  of  atropine  sulphate 
(sufficient  to  kill  an  infant)  may  thus 
be  easily  detected  in  the  urine. 

Atropine  is  a  true  diuretic  and  more 
powerful  than  any  other  that  we  possess, 
though  in  medicinal  doses  the  diuretic 
effect  is  often  masked  by  retention  of 
urine.  There  is,  after  taking  atropine, 
an  increased  elimination  of  all  the  solids 
(excepting  generally  the  chlorine);  the 
urea  is  always  increased,  often  to  a  con- 
siderable extent,  and,  most  of  all,  the 
phosphates  and  sulphates,  which  are 
sometimes  doubled. 

Atropine  diminishes  the  quantity  of 
urine;  it  diminishes  the  total  quantity 
and  percentage  quantity  of  urea;  it 
increases  relatively,  and  in  many  cases 
absolutely,  the  amount  of  nitrogen,  other 
than  that  contained  in  urea.  These 
effects  cannot  be  attributed  to  the  in- 
fluence which  the  alkaloid  exercises  upon 
blood-pressure.      How    atropine    acts    to 


ATROPINE.     PHYSIOLOGICAL  ACTION. 


539 


produce  an  elevation  of  the  bodily  tem- 
perature has  not  been  definitely  deter- 
mined. Thompson  (Jour,  of  Phys.,  Dee., 
'93). 

Sulphate  of  atropine  was  injected  into 
the  external  jugular  veins  of  rabbits  first 
narcotized  by  chloral-hydrate,  and  the 
urine  flowing  from  a  cannula  in  the 
bladder  measured  every  five  minutes, 
registering  the  blood-pressure  at  the 
same  time.  The  dose  of  the  atropine 
salt  used  (Vn  grain)  was  large,  but  this 
quantity  is  well  tolerated  by  rabbits; 
sometimes  the  dose  was  frequently  re- 
peated, and  sometimes  a  still  larger  one 
was  employed.  In  all  but  one  the  atro- 
pine was  injected  after  I  had  raised  the 
secretion  of  urine  by  the  intravenous 
injection  of  urea,  caffeine-sulphonic  acid, 
or  theobromine-sodium  salicylate.  The 
results  of  the  experiments  show  that  a 
diminution  of  the  flow  of  urine  usually 
follows  the  intravenous  Injection  of 
atropine,  independently  of  the  blood- 
pressure,  which  is  often  raised.  A  series 
of  experiments  made  with  difi'erent 
strengths  and  quantities  of  urea  solu- 
tions seem  to  show  that  the  kidneys  are 
not  injured  even  when  large  quantities 
of  urea  are  injected.  Albumin  was  only 
occasionally  met  with  after  the  injection 
of  urea,  and  then  in  mere  traces,  though 
small  quantities  of  sugar  were  found 
when  an  increased  urinary  flow  had  been 
produced  by  large  quantities  of  urea. 
Walti  (Arehiv  f.  exper.  Path,  und  Phar., 
B.  36,  H.  5,  6,  '95). 

Atropine  decreases  the  amount  of 
urine,  apparently  by  virtue  of  a  para- 
lyzing action  on  the  terminations  of  the 
vagus.  Lazaro  and  Pitini  (Archivo  di 
Farm,  e  Ter.,  v;  Deutsche  med.-Zeit., 
Feb.  3,  '98). 

Case  in  which  patient  took  1.5  to  20 
drops  of  an  atropine  solution  which  had 
been  ordered  for  him  for  a  conjunctivitis. 
AVhen  examined  he  showed  sugar  in  his 
urine.  After  this  had  disappeared  it  was 
found  that  100  grammes  of  grape-sugar 
would  readily  produce  an  alimentary 
glycosuria,  and  that,  therefore,  he  was 
a  ready  subject  of  alimentary  glycosuria. 
The  administration  of  large  doses  of 
atropine  to  guinea-pigs  produced  in  four 
or  five  attempts  the  appearance  of  gly- 


cosuria.    In  some  of  these  cases  grape- 
sugar  was  given  to  them  at  the  same 
time.      In    some,    it   was,    therefore,    an 
alimentary  glycosuria;    in  others  it  ap- 
peared   spontaneously    when    no    grape- 
sugar  was  given,  and  was  evidently  due 
to    the    atropine.      (Deut.    med.    Woch., 
July  13,  '99). 
The  action  of  atropine  on  the  sympa- 
thetic nervous  system  and  the  circula- 
tion is  that  of  a  direct  and  powerful 
stimulant.      During    the    operation    of 
medicinal  doses  the  heart  contracts  with 
increasing  vigor,  the  arteries  increase  in 
tone  and  volume,  the  capillary  system  is 
also  stimulated,  and  a  diffused  warmth 
is  felt  throughout  the  body.    If  the  dose 
be  excessive,  overstimulation  is  prodttced 
and  signs  of  exhaustion  are  soon  mani- 
fest.     The    maximum    stimulant    effect 
follows  the  itse  of  moderate  doses  only, 
generally  ^/os  grain,  not  more  than  V^s 
grain. 

Several  experiments  made  prove  that 
the  rise  of  temperature  is  not  spinal,  as 
heretofore  held  by  me.     The  results  ob- 
tained  with   the    ingestion    of   atropine, 
after  various  operations,  such  as  section 
in  front  of  the  pons  Varolii  and  of  the 
medulla    oblongata,   were    so   similar  to 
those  obtained  after  the  same  operations 
without  atropine  that  I  find  it  difBcult 
to   speak  accurately  as  to  the  cerebral 
centre  affected.     The  slight  rise  of  tem- 
perature   observed    in    the    rabbit    after 
puncturing    the    medulla    oblongata    or 
pons  Varolii  has  not  led  me  to  believe 
in    the    existence,   in   these    bodies,    of 
thermogenic    centres.      I    therefore    con- 
clude that,  until  the  existence  of  heat- 
centres  in  the  medulla  and  pons  has  been 
accurately   determined,   it   is   useless   to 
assume   that   atropine   acts   upon   them. 
Ott    (Jour,    of   Nerv.   and   Mental    Dis., 
Nov.,  '93). 
The  skin  becomes  the  seat  of  a  sensa- 
tion of  warmth  followed  by  a  temporary 
blush,    and   in   children   and    adults    of 
light  complexion  is  sometimes  followed 
by  a  scarlet  suffusion,  described  by  some 
as    a   "scarlatinous    rash."      In    persons 


540 


ATROPINE.     POISONING. 


subject  to  vascular  irritation  of  the  skin 
the  redness  remains  and  its  disappear- 
ance may  be  attended  with  slight  rough- 
ness and  desquamation.  Harley  states 
that  the  general  effect  of  atropine  on 
the  circulation  predisposes  to  sweating; 
but  Einger,  Bartholow,  and  others  as- 
cribe to  atropine  a  strong  inhibitory 
action  over  the  sweat-glands.  Certain 
it  is,  however,  that  atropine  inhibits  the 
secretory  function  of  the  mammary  and 
salivary  glands. 

As  regards  the  function  of  the  liver, 
Harley  believes  atropine  to  be  a  chola- 
gogue.  By  the  action  of  atropine  upon 
the  unstriped  muscular  fibres,  intestinal 
peristalsis  is  intensified. 

Experiments  made  upon  two  persons 
suffering  from  gastric  catarrh  and  two 
others  who  were  in  a  state  of  health 
showing  that  atropine  distinctly  lessens 
the  secretion  of  the  gastric  juice.  When 
medicinal  doses  were  used  in  healthy 
persons  the  decrease  was  very  marked, 
^yhile  in  those  who  had  gastric  catarrh 
no  changes  were  noted.  Panow  (Wratsch, 
No.  7,  '90). 

Atropine,  in  doses  of  V4  grain,  is  able 
to  instantly  kill  the  leucocytes  contained 
in  3  V3  ounces  of  human  blood,  and  in 
quantities  of  V3  gi"ain  the  leucocytes 
contained  in  3  Va  ounces  of  human  blood 
live  but  a  few  hours.  On  the  other 
hand,  the  leucocytes  contained  in  3  '/a 
ounces  of  blood  of  the  rabbit  were  not 
affected  by  a  dose  of  V3  grain  of  atro- 
pine. Maurel  (Bull.  Gen.  de  Ther.,  Apr. 
15,  '92). 

Atropine,  like  quinine,  in  daily  doses 
of  V„4  grain  produces  a  lessening  in  the 
number  of  leucocytes  in  the  blood  and 
in  the  amount  of  uric  acid  eliminated  by 
the  kidneys.  Horbaczewski  (Revue  de 
Ther.  Gen.  et  Thermal,  Sept.  20,  '92; 
These  de  Bordeaux,  T.  C,  Dec.  3,  '92). 
While  acting  as  a  depressant  to  the 
hepatic  function,  atropine  causes  no 
change  in  the  amount  of  iron  in  the 
liver,  and  only  a  slight  diminution  in 
the  quantity  of  glycogen.  Brunton  and 
Delgpine  (Proceedings  of  the  Royal  So- 
ciety, No.  234,  '94). 


Dilatation  of  the  pupil  is  a  prominent 
effect  of  atropine,  however  introduced 
into  the  system,  accompanied  by  tem- 
porary paralysis  of  the  muscle  of  accom- 
modation. 

In  its  action  on  the  cerebro-spinal 
system  the  general  effects  of  atropine 
resemble  those  of  opium  in  that  it  is 
both  an  excitant  and  hypnotic,  but  the 
soporific  effect  is  less  marked;  and  coma, 
if  it  occurs,  must  be  considered  a  remote 
consequence  rather  than  a  direct  effect 
of  the  action  of  the  drug.  After  large 
doses  insomnia  and  delirium  arise  and 
poisonous  doses  prolong  these  effects  for 
hours,  and  coma  gradually  supervenes. 
Headache,  vertigo,  illusions,  hallucina- 
tions, a  busy  delirium,  and  sometimes 
somnolence  are  produced  by  large  doses. 
More  or  less  ansesthesia  of  the  sensory 
centres  of  the  cerebrum.  The  action  on 
the  motor  centres  and  the  spinal  cord 
is  comparatively  slight.  The  corpora 
striata  participate  both  in  the  hypnotic 
and  in  the  excitant  effects.  Giddiness 
and  muscular  weakness,  from  inability 
for  exertion,  accompany  the  hypnotic 
effect,  while  restlessness  and  insomnia 
occur  when  the  hypnosis  is  overruled  by 
the  excitant  action.  The  spinal  cord  is 
least  of  all  affected  by  atropine. 

Atropine  Poisoning.  —  Fatalities  from 
atropine  are  comparatively  rare,  for  the 
lethal  effect  comes  on  very  slowly,  and 
generally  gives  time  both  for  appropriate 
treatment  and  for  its  elimination  through 
the  natural  channels.  One-half  grain  of 
atropine  has  proved  fatal,  though  Harley 
reports  recovery  after  the  ingestion  of 
1  ^/j  grains. 

The  symptoms  of  poisoning  are,  in 
general,  those  following  the  use  of  a 
large  dose  (previously  described),  but 
more  intensified.  The  action  of  the 
heart,  however,  while  increased  in  fre- 
quency, is  diminished  in  force;    the  ar- 


ATROPINE.     POISONING.     TKEAT3IENT. 


541 


terial  tension  becomes  subnormal;  the 
pnlse  weak  and  its  rhythm  disturbed. 
As  the  vascular  pressure  falls,  the  skin 
cools,  its  color  fades,  and  it  becomes 
covered  with  clammy  sweat.  The  de- 
lirium, at  first  mild  and  happy,  becomes 
unpleasant  or  disagreeable,  or  may  take 
the  character  of  the  delirium  of  terror, 
resembling  the  maniacal  type.  The 
respiration  becomes  feeble,  superficial, 
rapid,  and  irregular.  Disturbance  of  the 
respiratory  functions  and  the  impaired 
action  of  the  heart  and  blood-vessels 
cause  passive  congestion  of  the  lungs 
and  brain.  The  urine,  previously  in- 
creased in  amoiTnt,  is  diminished  or  even 
suppressed  from  lessened  vascular  press- 
iire.  Post-mortem  examination  reveals 
a  distension  of  the  right  heart  and  con- 
gestion of  the  brain,  lungs,  and  abdom- 
inal viscera. 

More  deaths  have  followed  medicinal 
doses  of  atropine  than  of  any  other  drug; 
if  possible,  therefore,  other  drugs  should 
be  substituted  for  it.  Atropine  has  been 
used  in  the  following  diseases:  1.  Neu- 
ralgia and  other  painful  affections.  Con- 
sidering the  large  number  of  analgesics 
available,  it  should  be  used  in  the  pres- 
ent day  in  exceptional  cases  only, — for 
example,  in  angina  pectoris.  2.  Whoop- 
ing-cough and  asthma.  If  the  cases  are 
severe  and  have  resisted  all  other  treat- 
ment, atropine  may  be  tried.  3.  The 
same  applies  to  epilepsy.  4.  It  is  very 
doubtful  whether  it  is  of  any  use  in 
hysteria,  paralysis  agitans,  and  other 
tremors.  5.  Chronic  constipation.  As 
there  are  plenty  of  substitutes,  its  use 
should  be  discontinued.  6.  Lead  colic. 
In  this  disorder  the  subcutaneous  use 
of  atropine  has  more  disadvantages 
than  advantages.  7.  Nocturnal  enuresis. 
Great  caution  is  necessary,  since  large 
doses  are  required,  as  a  rule.  8.  As  a 
cardiac  tonic,  and  in  those  eases  of  per- 
manent bradycardia  which  often  end  in 
epilepsy,  atropine  has  been  tried  without 
much  success  in  the  latter  cases,  possibly 
because  a  slow  pulse  does  not  always 
correspond  to  a  slowly  acting  heart.    Ac- 


cording to  Dehio,  it  may  benefit  slight 
cases  of  cardiac  irregularity,  but  is  with- 
out effect  in  severe  ones.  9.  In  night- 
sweats  it  acts  well;  but,  although  small 
doses  tend  to  prevent  collapse, — which 
is  common  in  phthisical  patients, — larger 
ones  increase  the  liability  to  it.  To  be- 
gin with  a  dose  of  Vim  grain  is  un- 
justifiable in  advanced  cases  of  phthisis. 
10.  In  chronic  hypersecretion  of  HC'l  by 
the  gastric  mucosa  several  observers 
have  found  that  atropine  diminished  the 
secretion,  but  others  deny  this.  How- 
ever, considering  the  bad  effects  of  this 
hypersecretion  on  the  gastric  mucosa,  in 
the  present  state  of  our  knowledge 
atropine  must  still  be  tried.  11.  Some 
observers  state  that  atropine,  given  hypo- 
dermically,  arrests  haemorrhage  (haemop- 
tysis, etc.)  by  its  action  on  the  arterioles. 

12.  The  injection  of  atropine  before  the 
administration  of  chloroform  to  prevent 
syncope  has  been  given  up  by  surgeons. 

13.  It  has  been  recommended  as  an  anti- 
dote to  barium  salts,  hydrocyanic  acid, 
nicotine,  pilocarpine,  and  muscarine 
poisoning.  14.  The  question  of  its  use 
as  an  antidote  to  opium  will  be  studied 
in  a  further  communication.  Lepine 
(Sem.  Med.,  Nov.  25,  '96;  Brit.  Med. 
Jour.,  Jan.  9,  '97). 

A  case  of  lobster  poisoning  simulating 
poisoning  with  atropine  in  one  man  and 
two  women.  Evacuation  was  induced 
only  after  large  doses  of  castor-oil,  senna, 
magnesium  sulphate,  and  several  soap 
enemata.  The  general  toxic  symptoms 
improved  under  the  hypodermic  adminis- 
tration of  pilocarpine  (V-  grain),  while 
for  the  eye  symptoms  it  was  found  neces- 
sary to  employ  eserine,  1  to  2  drops  of  a 
5-per-cent.  solution  twice  daily.  Fischer 
(Nouv.  Rem.,  Apr.  8,  '98). 

Treatment  of  Atropine  Poisoning.  — 
If  seen  early  enough,  €metics  or  warm 
drinks  should  be  administered,  followed 
by  the  use  of  the  stomach-titbe.  Tannin 
and  charcoal  may  be  used  if  a  stomach- 
tube  is  not  at  hand  and  absorption  has 
not  taken  place.  Among  the  antidotes 
advised  are  cofEee,  alcohol,  pilocarpine 
(Va  to  V4  grain),  muscarine  nitrate  (^/^o 
to  Vi5  grain),  morphine  sulphate  (Vs  to 


542 


ATROPINE.     POISONING.     TREATMENT.     THERAPEUTICS. 


V2  grain),  or  eserine  (V200  to  Veo  grain). 
The  violent  action  of  the  drug  should  be 
restrained  by  the  use  of  the  foregoing 
antidotes  given  by  hypodermic  injection, 
in  moderate  doses,  and  repeated  at  in- 
tervals, as  indicated  by  the  condition  of 
the  patient  and  the  urgency  of  the  symp- 
toms. 

Case  illustrating  the  paralyzing  influ- 
ence of  atropine,  but  also  demonstrating 
that  persistent  efl'ort  is  frequently  re- 
warded by  recovery  in  the  most  serious 
eases.     Begold  (Wratch,  No.  4,  p.  96,  '96) . 

The  antagonism  between  atropine  and 
morphine  is  not  as  pronounced  as  some 
investigators  claim.  Binz  in  cases  of 
opium-poisoning  gives  Vc  to  Vw  grain  of 
atropine,  while  Kobert  recommends  Voo 
grain  every  half-hour.  These  doses  are 
far  too  great  and  a  single  dose  of  only 
V4ii  grain  should  be  given.  E.  F.  Bash- 
ford  (Archives  Inter,  de  Pharm.  et  de 
Therap.,  vol.  viii,  p.  311,  1901). 

There  can  be  no  doubt  that  atropine 
may  be  of  value  as  an  antidote  in  mor- 
phine poisoning,  but  only  before  the 
third  stage,  and  then  only  when  given 
in  small  or  moderate  doses.  But  even 
here  its  usefulness  is  practically  limited 
to  a  possible  excitation  of  the  respira- 
tory movements  and  a  stimulation  of 
the  circulation,  both  of  which,  however, 
may  be  fully  compensated  for  in  its  per- 
nicious effects,  chiefly  upon  general 
metabolism.  Given  in  large  doses  dur- 
ing the  second  stage,  or  in  moderate  to 
large  doses  during  the  third  stage,  it 
almost,  if  not  without  exception,  does 
harm  by  intensifying  the  morphine  con- 
dition, prolonging  or  shortening,  but  in- 
tensifying, the  second  stage,  or  shorten- 
ing the  third  stage,  and  hastening  the 
fatal  issue.  If  the  second  stage  is  short- 
ened, it  is  owed  to  the  earlier  develop- 
ment of  the  third  stage  of  the  poisoning. 
This  has  been  personally  found  to  be  a 
uniform  result  of  a  large  number  of  ex- 
periments upon  dogs,  and  which  is  fully 
supported  by  the  records  of  other  in- 
vestigators. In  fact,  a  dose  of  morphine 
that  is  not  lethal  may  be  made  so  by 
the   synergistic   actions   of   a   sublethal 


dose  of  atropine.  E.  T.  Reichert  (Ther. 
Monthly,  May,  1901). 
Therapeutics.  —  Disorders  of  the 
Eye. — Atropine  is  greatly  employed  in 
ophthalmological  work,  not  only  as  a 
therapeutic  agent,  but  largely  in  diag- 
nosis, as  it  dilates  the  pupil,  diminishes 
intra-ociilar  pressure,  contracts  the  ar- 
terioles, and  acts  topically  on  the  senti- 
ent nerves.  Atropine  is  used  when  we 
wish  to  suspend  the  power  of  accommo- 
dation in  cases  of  myopia  or  hyperme- 
tropia  to  determine  the  exact  error  of 
refraction,  and  in  astigmatism  to  ascer- 
tain the  difference  in  the  meridians.  In 
the  examination  of  cataract  (especially 
in  its  early  stages)  the  use  of  atropine  is 
of  great  value.  A  wider  and  better  view 
of  the  fundus  of  the  eye  is  also  obtained 
through  the  pupil  dilated  by  atropine. 
As  a  therapeutic  means,  atropine  is  in- 
valuable in  all  superficial  inflammatory 
conditions  of  the  eye  in  which  pain, 
tenderness,  and  photophobia  are  present. 
Mild  solutions  (1  or  2  grains  to  1  ounce) 
instilled  within  the  eyelids  generally  give 
prompt  relief.  In  strumous  corneal 
ulcers  and  phlyctenular  keratitis  (by 
diminishing  photophobia  and  blepharo- 
spasm and  lessening  blood-supply)  a  few 
drops  of  a  mild  solution  (1  grain  to  1 
ounce)  two  or  three  times  daily  will  give 
relief.  In  syphilitic  iritis  where  poste- 
rior or  anterior  synechias  are  a  frequent 
complication,  early  and  constant  dila- 
tation of  the  pupil  should  be  secured 
through  the  use  of  solutions  of  atropine 
(2  to  4  grains  to  1  ounce).  Atropine 
will  relieve  the  photophobia  of  acute 
conjixnctivitis  and  also  that  of  chronic 
conjunctivitis  associated  with  blepharitis 
and  granular  lids,  if  used  in  mild  solu- 
tion and  not  too  frequently  applied. 

In  the  treatment  of  iritis  the  action 
of  atropine  is  often  augmented  by  the 
use  of  the  Turkish  bath.  Claiborne  (N. 
C.  Med.  .Jour.,  '92). 


ATROPINE.     THERAPEUTICS. 


543 


As  a  general  rule,  the  treatment  of 
axial  myopia  without  glasses  will  im- 
prove the  vision  to  that  previously  ob- 
tained with  glasses.  I  use  atropine,  with 
local  bathing  witli  hot  water,  and  leeches 
to  the  temple.  Dark  glasses  are  worn  to 
protect  the  eyes  from  light,  and  astrin- 
gents are  applied  to  the  conjunctiva. 
Bates   (Med.  Record,  Jan.  27,  '94). 

In  penetrating  wounds  of  ciliary  re- 
gion and  lens,  even  where  light-percep- 
tion is  gone  and  where  usually  enuclea- 
tion, is  performed,  removal  of  lens  will 
often  be  followed  by  recovery  of  com- 
paratively useful  vision;  operation  to 
be  performed  during  first  week  of  injury. 
Irritating  solutions  to  be  avoided.  After- 
treatment:  atropine,  I  per  cent.,  every 
four  hours,  and  compress  bandage.  Ran- 
dolph (N.  y.  Med.  Jour.,  Feb.  23,  '95). 

The  inflammatory  conditions  necessi- 
tating the  use  of  atropine  are  confined 
to  the  eye  itself;  it  is  not  indicated  in 
inflammations  of  the  appendages.  Scleri- 
tis  and  episcleritis  will  generally  yield 
to  appropriate  treatment,  without  myd- 
riasis, also.  In  keratitis,  atropine  is 
indicated  because  it  paralyzes  accommo- 
dation, thereby  relieving  the  cornea  from 
any  action  the  ciliary  muscles  may  in- 
directly have  on  it,  and  because  it  acts  as 
an  antesthetic  to  a  limited  degree.  I 
have  never  seen  glaucomatous  symp- 
toms arise  from  the  use  of  atropine  in 
keratitis,  but  conjunctival  irritation  in 
this  connection  is  not  uncommon. 

In  iritis  atropine  is  indicated  at  once, 
and  the  sooner  the  iris  is  brought  fully 
under  its  influence,  the  better;  and  espe- 
cially is  this  true  of  the  plastic  variety. 
In  serous  iritis,  without  plastic  exuda- 
tion, mydriatics  act  by  dilating  the  iris, 
thereby  relieving  pain.  In  the  plastic 
variety,  not  only  is  this  the  case,  but 
they  also  overcome  the  danger,  if  used 
in  the  onset  of  the  disease,  of  adhesions 
being  formed  between  the  iris  and  the 
anterior  capsule  of  the  lens,  constituting 
what  is  know  as  posterior  synechia.  In 
inflammation  of  the  ciliary  body,  cyclitis, 
atropine  is  indicated  as  an  antiphlogistic 
and  analgesic.  In  inflammations  of  the 
deeper  structures  of  the  eye,  as  in  hya- 
litis,  retinitis,  choroiditis,  and  even  hfem- 
orrhage,  I  believe  atropine  has  a   place. 


There  is  a  difference  of  opinion  here, 
some  holding  that  the  enlargement  of  the 
pupil  from  atropine  allows  more  light  to 
enter  the  eye  than  is  good  for  the  in- 
flamed structures,  which  is  a  fact;  but 
the  paralyzing  of  the  accommodation,  it 
seems  to  me,  is  beneficial,  especially  when 
one  can  exclude  the  light  by  means  of 
very  dark  glasses.  The  greatest  fear  to 
be  entertained  from  the  use  of  atropine — 
and,  in  fact,  of  all  mydriatics — is  increase 
of  tension;  but  this  should  be  a  desir- 
able aid  in  case  of  haemorrhage  from  the 
retinal  vessels.  In  simple  optic  neuritis 
atropine  is  not  beneficial. 

The  contra-indications  for  the  use  of 
atropine  can  be  inferred  from  what  I 
have  already  said,  but  the  greatest  fear, 
and  one  which  even  the  most  experi- 
enced feels,  is  the  possibility  of  precip- 
itating an  attack  of  acute  glaucoma. 
Van  Fleet   (Med.  News,  Feb.  5,  '96). 

Clinical  study  of  action  of  mydriatics 
and  myotics  on  12  cases  of  total  oculom- 
otor palsy  shows  that  ati'opine  widened 
the  pupil  an  additional  I  millimetre  to 
1  y.  millimetres,  which  is  attributed  to 
the  action  of  the  mydriatic  on  nerve- 
ends  and  fibres  that  were  not  completely 
paralyzed,  rather  than  to  its  influence  on 
the  sympathetic  neiwe.  Sprio  (Centralb. 
f.  prakt.  Augenh.,  Mar.,  '98). 

Atropine  should  not  be  used  in  con- 
junctival troubles,  in  glaucoma  or  in- 
creased intra-ocular  tension,  or  as  a  myd- 
riatic in  patients  over  forty.  It  is  indi- 
cated in  iritis,  keratitis,  and  corneal  ulcer 
and  may  be  used  diagnostically  to  dilate 
the  pupil  and  to  relax  accommodations  in 
persons  under  thirty  or  thirty-five  years. 
Marple  (Phila.  Poly.;  Post-grad.,  May, 
'98). 

In  ocular  therapeutics  the  greatest  in- 
dication is  in  iritis,  whether  rheumatic, 
traumatic,  syphilitic,  or  idiopathic.  In 
adults  1  drop  of  a  1-per-cent.  solution 
usually  sufiices  to  dilate  the  pupil  fully 
if  instilled  every  two  or  three  hours.  In 
children  of  one  to  five  years,  'A-of-l-per- 
cent.  solution  should  be  used.  Intoler- 
ance of  the  drug  is  shown  by:  (1)  toxic 
symptoms,  as  dry  throat,  nausea;  (2) 
the  production  of  catarrh  [this  usually 
follows  long-continued  use] ;  (3)  redness 
and  swelling  of  the  lid.s.     It  is  indicated 


544 


ATROPINE.     THERAPEUTICS. 


in  all  traumatisms  of  the  eye  when  iritic 
or  eyelitic  involvement  is  suspected,  in 
corneal  inflammations,  ulcer  of  the  cor- 
nea, and  to  dilate  the  pupil  for  ophthal- 
moscopic examination.  Among  the 
abuses  cited  are  its  uselessness  or  even 
positively  injurious  effects  in  simple  un- 
complicated conjunctivitis,  not  only  be- 
cause it  possibly  may  increase  the  con- 
junctival inflammation,  but  because 
of  the  unnecessary  inconvenience  of 
disturbed  vision.  It  should  never  be 
used  simply  to  dilate  the  pupil  tem- 
porarily in  patients  beyond  forty-five 
years  of  age,  the  glaucomatous  tendency 
being  more  marked  at  this  time,  and  its 
instillation  can  readily  so  occlude  Fon- 
tana's  spaces  as  to  precipitate  an  attack 
of  acute  glaucoma.  Under  no  circum- 
stances should  it  be  used  in  glaucoma. 
A.  D.  McConaehie  (Maryland  Med.  Jour., 
No.  13,  p.  195,  '99). 

Neuralgia.- — Atropine  gives  very 
satisfactory  results  in  neuralgia,  espe- 
cially in  neuralgia  of  the  trigeminus,  and 
in  sciatica.  In  the  former,  a  solution 
of  the  drug  may  be  applied  externally 
over  the  painful  area  or  instilled  within 
the  eyelids,  or  injected,  not  subcutane- 
ously,  but  deeply,  into  the  tissues  in 
the  neighborhood  of  the  affected  nerve- 
trunk.  In  sciatica  the  last  method  is 
the  best.  The  largest  dose  compatible 
with  the  safety  of  the  patient  must  be 
used  (generally  Vso  to  V30  grain),  and 
decided  curative  results  may  be  expected 
(Bartholow).  In  traumatic  neuralgias 
Weir  Mitchell  asserts  that  atropine  is 
useless.  Earache,  when  neuralgic  in 
character  and  not  produced  by  pressure 
of  pus  against  the  tympanum,  may  be 
relieved  by  instilling  a  few  drops  of  a 
solution  of  atropine,  previously  warmed. 
Periuterine  and  dysmenorrhosal  neural- 
gias are  relieved  by  deep  hypodermic 
injections  of  atropine  in  solution.  Mus- 
cular cramp  from  injuries  to  the  nerve- 
trunk  are  often  relieved  by  atropine,  in- 
jected into  the  substance  of  the  affected  I 


muscle.  Hepatic,  intestinal,  uterine, 
and  renal  colic  may  be  relieved  by  hyp- 
odermic injections  of  atropine,  but  the 
best  results  are  reached  when  morphine 
and  atropine  are  combined.  Vaginis- 
mus has  been  relieved  by  the  topical  use 
of  pledgets  of  lint  wet  with  a  mild  solu- 
tion of  atropine. 

Insomnia. — The  insomnia  of  mental 
disorders  and  of  delirium  tremens  may 
be  overcome  by  the  hypodermic  injec- 
tion of  atropine  when  the  following  in- 
dications for  its  use  are  present:  Coma 
vigil,  great  restlessness,  weak  heart,  cold 
surface,  cyanosis,  clammy  sweat.  When 
there  is  a  condition  of  hypersemia  of  the 
cerebro-spinal  centres  (excitement  with 
elevated  pulse-rate  and  increased  arterial 
tension)  atropine  can  only  do  harm. 
(Bartholow.) 

Asthma. — Atropine  in  doses  of  V120 
to  Voo  grain,  given  hypodermically,  will 
relieve  the  paroxysms  of  asthma,  espe- 
cially if  given  at  the  beginning  of  the 
paroxysm.  Here  the  effect  is  systemic 
and  the  injection  need  not  be  made  over 
the  pneumogastric. 

Cutaneous  Disobdees. — Atropine  in 
soMion  (4  grains  to  1  ounce)  may  be 
applied  externally  in  all  painful  and 
congested  conditions  of  the  skin.  Ery- 
thematous dermatitis,  erysipelas  simplex, 
pruritus  of  the  vulva,  and  fissure,  etc., 
may  be  relieved  in  this  way.  The  pain 
of  cancerous  infiltrations  of  the  skin 
may  be  relieved  by  painting  the  surface 
with  an  atropine  solution  and,  when  the 
skin  has  become  disintegrated  through 
sloughing,  lint  dipped  in  a  weak  solu- 
tion of  atropine  and  applied  to  the  sur- 
face gives  relief. 

The  troublesome  pruritus  of  icteric  and 
diabetic  patients  is  best  dealt  with  by 
calmative  applications,  as  a  flannel  com- 
press saturated  with  a  solution  of  atro- 
pine, 1  to  500,  covered  with  a  sheet  of 


ATROPINE.     THERAPEUTICS. 


543 


oiled  silk.     Besnier  (Bull,  de  la  Soc.  de 
M6d.  d'Anvera,  May,  '91). 

Mammary  Congestion.  —  When  the 
glands  are  swelled  or  tender,  either  early 
in  lactation  or  later,  when  we  wish  lac- 
tation to  cease  (on  death  or  removal  of 
infant  or  weaning),  atropine  (4  grains 
to  1  ounce  of  rose-water)  is  a  clean  and 
eflScient  remedy  to  apply  to  the  glands. 
The  gland  is  first  cleaned  with  soap  and 
warm  water,  carefully  dried,  and  the 
solution  of  atropine  applied  to  the  sur- 
face (avoiding  the  nipple  and  the  areola) 
with  a  camel's-hair  brush  and  allowed  to 
dry.  The  glands  should  then  be  drawn 
upward  and  inward  (to  take  oil  weight 
and  tension)  and  retained  by  means  of  a 
proper  bandage.  If  preferred,  the  breast 
may  be  enveloped  in  lint  wetted  with 
the  above  solution.  If  the  pupils  dilate 
and  the  mouth  becomes  dry,  the  applica- 
tion should  be  removed. 

Excessive  Diaphoresis. — The  night- 
sweats  of  phthisis  may  be  checked  by 
the  subcutaneous  injection  of  atropine; 
Veo  grain  at  bed-time  usually  suffices 
(Bartholow).  The  copious  perspiration 
induced  by  drugs,  such  as  pilocarpine, 
opium,  alcohol,  and  other  diaphoretics, 
may  be  cheeked  by  the  use  of  atropine. 
Collapse. — Since  atropine  stimulates 
the  heart  and  increases  the  blood-press- 
ure, we  find  it  useful  in  moderate  doses 
in  the  collapse  of  fevers,  cholera,  sun- 
stroke, and  cardiac  syncope.  The  dan- 
gerous exhaustion  consequent  upon  col- 
liquative diarrhoea  and  internal  haemor- 
rhage indicate  the  use  of  atropine.  It 
is  also  valuable  for  the  prevention  of 
shock  after  operative  procedures  and 
anaesthesia. 

Atropine — '/to  to  '/i„„  grain  given  be- 
fore the  administration  of  ether — reduces 
the  chances  of  shock.  Case  of  a  woman, 
who,  in  a  preliminary  examination,  came 
out  of  the  influence  of  ether  in  a  de- 
plorable state;  three  days  later,  how- 
l- 


ever, when  the  operation  was  about  to 
be  performed,  atropine  was  given,  and 
she  was  taken  from  the  table  with  as 
good  a  pulse  as  before  anaesthesia.  Lewis 
A.  Stimson  (N.  Y.  Med.  Jour.,  Mar.  9, 
'89). 

The  combination  of  atropine  and  mor- 
phine prior  to  ether  inhalation,  injected 
hypodermieally,  checks  the  after-vomit- 
ing and  is  preferable  to  bromides,  chloral, 
and  opium,  all  of  which  often  fail  to 
produce  good  results.  Rushmore  (Jour. 
Amer.  Med.  Assoc,  Mar.  19,  '93). 

Atropine  by  promoting  contraction  of 
the   arteries   antagonizes   the    dangerous 
fall  of  blood-pressure  produced  by  chloro- 
form.    It  may  be  used  by  intravascular, 
hypodermic,     or    intravenous     injection. 
Schafer    (Lancet,   Feb.   5,   '98). 
Excessive  Vomiting.- — Atropine  used 
hypodermieally   has  been   found   useful 
in  some  cases  of  seasickness  and  in  the 
vomiting  of  pregnancy. 

Atropine  is  also  available  in  a  variety 
of  other  diseases,  judging  from  the  evi- 
dence adduced. 

Cholera  Infantum.  —  Beneficial  ef- 
fects have  been  obtained  by  Larrabee  by 
means  of  hypodermic  injections  of  ^/^o 
grain  of  atropine  followed  by  calomel 
and  lime-water  containing  a  little  car- 
bolic acid.  Nothing  but  toast-water  was 
allowed  for  thirty-six  hours. 

William  Bailey,  of  Louisville,  has 
found  that  infants  bore  atropine  well, 
and  gave  almost  adult  doses  of  atro- 
pine to  children  only  a  few  months  old, 
combining  the  drug  with  relatively  very 
small  doses  of  morphine:  for  instance, 
Vso  grain  of  morphine  and  Viso  grain 
of  atropine,  repeated  two,  three,  or  four 
times  in  twenty-four  hours,  making  the 
adult  dose  of  atropine.  This  controls 
— he  states — the  phenomena  of  cholera 
infantum,  which  would  terminate  life 
perhaps  in  a  few  hours  without  such 
treatment. 

Lauder   Brunton   observed   a   case   in 
which  a  child  was  collapsed  and  appar- 
35 


546 


ATROPINE.     THERAPEUTICS. 


ently  dying.  A  subciitaneous  injection 
of  atropine  revived  her  for  a  time.  This 
was  followed  by  relapse;  but  another 
injection  was  administered,  with  good 
results,  and  she  recovered. 

Influenza.  —  For  the  delirium  of 
inanition  and  allied  states,  when  fotind 
as  sequels  of  influenza,  Sachs  found  that 
there  was  nothing  better  than  subcutane- 
ous injections  of  atropine  and  morphine. 
H.^iMOERHAGic  DisoEDEES. — Atropine 
has  been  highly  recommended  in  many 
disorders  characterized  by  an  undue  flow 
of  blood. 

In  two  cases  of  metrorrhagia  this  drug 
acted  well  as  an  hsemostatic.  One  was 
of  a  fortnight's  standing  and  had  been 
treated  by  ergot  internally  and  tam- 
pons in  vagina;  the  bleeding  completely 
ceased  after  four  injections — each  of  V.oo 
grain  of  atropine — used  twice  daily. 
The  other;  a  most  severe  case,  had  been 
persistently  treated  by  hydrastis  Cana- 
densis and  ergot  internally  and  ice  lo- 
cally, without  avail.  Marked  improve- 
ment followed  half  an  hour  after  the 
first  hypodermic  injection  of  atropine; 
the  bleeding  had  notably  lessened  soon 
after  the  second  injection,  given  five 
hours  later,  and  completely  ceased  after 
the  third,  given  twelve  hours  after  the 
first.  Dimitrieff  (Revue  Scien.  et  Ad- 
minis,  des  M6d.  des  Armees  de  Terre  et 
de  Mer,  Xo.  50,  '91;  Brit.  Med.  Jour., 
May  21,  '92). 

Four  cases  of  uterine  hasmorrhage  of 
alarming  character,  wherein  all  other 
methods  failed,  were  controlled  by  atro- 
pine employed  hypodermically:  Voo  grain 
repeated  in  three  hours,  and  a  third 
given  twelve  hours  later.  Dimitrieff  re- 
ports two  cases  treated  in  this  way  with 
good  results.  Strizdred  (Univ.  Med. 
Mag.,  Sept.,  '92). 

Five  cases  of  uterine  hfemorrhages  in 
which  atropine  sulphate  was  used  with 
very  gratifying  results,  when  the  usual 
remedies  failed.  Two  cases  were  post- 
partum, three  were  simple  menorrhagia, 
and  the  last  from  uterine   cancer.     The 


dose  administered  was  '/mo  grain  every 
two  hours,  per  mouth.  W.  G.  Johnson 
(Penna.  Med.  Jour.,  Feb.,  '98). 
Morphinism.  —  Koehs,  of  Bonn,  em- 
ployed subcutaneous  injections  of  atro- 
pine as  an  antidote  to  morphinism  in  five 
cases,  diminishing  the  unpleasant  results 
of  abstinence.  He  says  that  ^/goo  grain 
of  the  sulphate  should  be  given  at  first, 
patient  being  watched  for  several  hours. 
A  second  dose  may  be  given,  if  necessary. 
I  cannot  approve  of  this  treatment.  In 
most  cases  the  quantity  of  the  morphine 
should  be  slowly  diminished,  thus  reduc- 
ing the  suffering  to  a  minimum.  (Nor- 
man Kerr.) 

Antidotal  Uses. — In  opium  poison- 
ing Harley  advises  the  use  of  atropine, 
in  doses  sufficient  to  stimulate  the  cir- 
culation and  respiration,  whereby  the 
secretion  of  urine  is  increased  and  the 
elimination  of  the  poison  hastened.  For 
this  purpose  Vso  to  ^/eo  grain  should  be 
given  hypodermically  every  hour  or  two, 
according  to  the  gravity  of  the  symp- 
toms and  the  response  of  the  nervous 
system  to  the  remedy.  The  same  re- 
marks apply  to  the  treatment  of  poison- 
ing by  calabar-bean  (physostigmine — 
eserine),  for  which  atropine  is  a  more- 
decided  antidote. 

In  three  patients  who  had  formerly 
suffered  from  tinnitus  aurium  due  to 
quinine,  the  symptoms  could,  at  least, 
be  considerably  diminished  by  adding 
atropine  to  the  quinine.  The  amount  of 
atropine  prescribed  amounted  to  '/no- 
grain  daily.  Aubert  (La  Mgd.  Mod., 
Mar.  24,  '97). 

Internal  Uses. — The  indications  for 
the  internal  uses  of  atropine  will  be 
considered  under  the  head  of  Bella- 
donna. 

C.    SuiINER    WiTHERSTINE, 

Philadelphia. 


BARIUM.     PHYSIOLOGICAL  ACTION.     THERAPEUTICS. 


547 


B 


BARIUM.  —  Barium  is  not  employed 
medicinally,  and  is  of  no  interest  to 
phj'sicians  except  as  they  may  require  its 
aid  for  purposes  of  chemical  research. 
So,  too,  of  the  fifty  salts  of  the  metal, 
but  two — the  chloride  and  sulphocarbo- 
late  have  ever  been  employed  therapeu- 
tically, and  even  then  only  in  a  desultory 
and  incomplete  way.  The  dioxide  and 
sulphide  bear  a  quasirelation  to  medi- 
cine, however,  but  in  a  chemical  rather 
than  a  therapeutic  sense,  the  former 
being  employed  in  the  manufacture  of 
hydrogen  dioxide,  while  the  latter  finds 
use,  when  mixed  with  starch  (1  to  3) 
and  water  to  the  consistency  of  cream, 
as  a  depilatory. 

Barium  chloride  is  a  white,  crystalline 
substance  possessed  of  a  bitter,  disagree- 
able taste.  It  is  readily  soluble  in  water, 
fairly  so  in  alcohol,  and  but  scarcely  at 
all  in  absolute  alcohol. 

Preparations  and  Dose. — Barium  chlo- 
ride, ^/,  to  2  grains. 

Barium  sulphoearbolate,  V^  to  1  grain. 

Physiological  Action. — A  recent  work 
on  therapeutics  is  responsible  for.  the 
statement  that  barium  chloride  in  its 
action  upon  the  circulation  resembles 
both  ergot  and  digitalis:  a  conclusion 
that  would  seem,  physiologically  speak- 
ing, self-contradictory.  Hypodermic  in- 
jections of  the  chloride  of  barium,  in 
doses  of  ^/i2  grain  per  pound  of  the 
body-weight,  produce  death  in  dogs  in 
twenty-four  hours  after  the  administra- 
tion of  the  drug.  With  smaller  amounts 
death  is  more  retarded,  but  the  toxic 
phenomena  produced  in  the  meantime 
are  vomiting,  diarrhoea,  albuminuria 
with  hematuria,  and  convulsions  pre- 
ceding the  fatal  termination.  The  most 
prominent  post-mortem  lesion  found  is 
nephritis  with  congestion  of  the  glome- 


rules,  ha2morrhages  in  the  tubes,  and 
lesions  in  the  cells  of  the  labyrinth. 
These  lesions  are  different  from  those 
caused  by  mercury;  they  consist  of  a 
granulo-fatty  infiltration  of  the  secre- 
tory epithelium  of  Heidenhain.  Traces 
of  hemoglobin  are  found  in  the  cells, 
this  hasmoglobin  soon  passing  into  the 
secreting  cells  and  afterward  into  the 
urine.  These  histological  changes  ex- 
plain the  phenomena  observed  during 
life:  albuminuria  and  hEemoglobinuria. 
(Pilliet  and  Malbec.) 

Barium  chloride  exerts  its  chief  in- 
fluence on  the  heart  and  resembles  very 
closely  in  its  effects  those  of  digitalis. 
In  the  frog  small  doses  increase  the  ac- 
tion of  the  heart-muscle,  and  large  doses 
arrest  this  viscus  in  systole.  The  inter- 
esting fact  was  discovered  that  a  heart 
arrested  by  muscarine  or  chloral  was 
started  again  by  using  this  salt,  and  it 
was  also  found  that  the  strongest  elec- 
trical stimulation  of  the  vagi  failed  to 
relax  the  systolic  spasm.  Furthermore, 
it  was  proved  that  this  loss  of  inhibitory 
control  was  not  due  to  a  depression  of 
these  nerves,  but  to  the  direct  cardiac 
effects.  In  warm-blooded  animals  the 
drug  slows  the  heart  solely  by  its  action 
on  this  viscus,  but  if  very  large  doses 
are  given  there  is  a  primary  acceleration 
of  the  pulse,  probably  due  to  stimulation 
of  the  accelerator  nerves.  Finally,  this 
is  replaced  by  slowing  caused  by  direct 
depression  of  the  heart-muscle.  Barium 
also  increases  to  a  marked  extent  arterial 
pressure,  and,  like  pilocarpine,  increases 
the  secretion  of  saliva.     (Bary.) 

The  foregoing  is  also  borne  out  by 
studies  made  by  Einger  and  Sainsbury. 

The  physiological  action  of  the  sul- 
phoearbolate has  not  been  investigated. 

Therapeutics.  —  Barium   chloride  has 


548 


BELLADONNA. 


been  tried  externally  in  a  multitude  of 
maladies,  but  in  such  a  way  that  it  is 
hardly  safe  to  attempt  to  deduce  conclu- 
sions of  a  definite  character  therefrom. 
Even  in  the  latter  part  of  the  last  cent- 
ury an  ointment  of  this  salt  was  sug- 
gested as  a  remedy  for  scrofulous  tumors; 
later  it  was  tried — as  have  been  most 
salts — as  an  application  to  goitrous 
swellings;  recently  Kobert,  of  Dorpat, 
attempted  to  relieve  dilated  cutaneous 
veins  by  application  of  a  solution  in- 
corporated with  lanolin,  "but  without 
result."  Strange  to  say,  a  late  work  on 
materia  medica  and  therapeutics  gives 
Kobert's  evidence  as  favorable  instead  of 
unfavorable,  the  error  arising  probably 
from  the  fact  that  Bartholow  rendered 
a  report  opposed  to  that  of  the  Russian 
observer. 

Internally  the  medicament  appears, 
vrhen  given  in  minute  dose,  to  be  both 
alterative  and  stimulant.  It  has  been 
employed  in  a  variety  of  diseases,  and  is,  • 
by  no  means,  new,  since  as  early  as  1789 
Crawford  recommended  it  to  be  admin- 
istered to  scrofulous  patients  and  applied 
as  an  ointment  to  scrofulous  swellings 
of  the  neck;  half  a  century  later  Walsh 
suggested  it  as  a  substitute  for  iodine  in 
like  cases.  Cases  of  the  cure  of  aneu- 
rism by  this  salt  have  been  reported  in 
current  medical  literature. 

Da  Costa  holds  that  in  valvular  disease 
of  the  heart  it  is  both  a  general  and 
cardiac  tonic,  "diminishing  and  relieving 
cardiac  distress,  increasing  the  tone  of 
the  blood-vessels,  and  producing  diu- 
resis; also  that  it  is  a  remedy  that  can 
be  taken  for  a  long  time  without  danger 
or  disordering  the  stomach."  This  is 
denied,  however,  by  Bardet,  who  also 
chronicles  a  death  after  ten  days'  use  of 
the  drug,  in  which  but  '■/j  grain  was  in- 
gested daily — total,  2  ^/„  grains.     This 


would  indicate  necessity  for  the  greatest 
caution  when  administered  internally. 

Several  writers  have  also  lauded  ba- 
rium chloride  in  functional  heart  mala- 
dies, but  the  evidence  adduced  'is  in- 
conclusive. Brown-Sequard  tried  it  in 
epilepsy  with  negative  results;  but  it 
appeared  to  him  to  be  of  value  in  tetanus 
and  paralysis  agitans.  Another  author 
recommends  it  in  diffuse  and  multiple 
cerebral  sclerosis,  but  without  even  a 
suggestion  as  to  the  rationale  thereof. 

It   has   been   administered   in   various 
cutaneous  diseases  in  doses  of  V™  grain 
three   times   daily,   and   is   said   to  cure 
the  irritable  forms  of  dry  eczema  after 
arsenic  has  failed.     Mineral  waters  con- 
taining barium  salts  have  long  enjoyed 
a  reputation  for  efficacy  in  skin  diseases. 
Armstrong     (Foster's    "Practical    Thera- 
peutics"). 
Barium  sulphocarbolate,  like  most  sul- 
phocarbolate  salts,  has  been  employed  in 
the   colliquative   diarrhosas   of   children, 
especially  those  suffering  from  rachitis, 
and  in  gastro-intestinal  disturbances,  but 
it  is  impossible,  as  yet,  to  draw  conclu- 
sions from  the  few  incomplete  reports 
that  have  been  rendered. 

BARLOW'S  DISEASE.  See  Scoe- 
BUTUS,  Infantile. 

BELLADONIJA.— Belladonna  (deadly- 
nightshade)  is  a  solanaceous  plant,  bo- 
tanically  known  as  Atropa  belladonna, 
Linne.  It  is  indigenous  to  southern 
Europe  and  central  Asia.  Two  parts  of 
the  plant  are  used  in  medicine:  the 
leaves  and  root.  The  preparations  are 
extract  (solid)  and  tincture  of  the  leaves, 
and  fluid  extract  of  the  root.  Bella- 
donna plaster  and  belladonna  ointment 
are  made  from  the  extract  of  the  leaves, 
but  belladonna  liniment  is  made  with 
fluid  extract  of  root.  The  active  prin- 
ciple is  the  alkaloid  atropine,  which  oc- 


BELLADONNA.     POISONING. 


549 


curs  in  the  plant  in  combination  with 
malic  acid  as  bimalate.  Another  prin- 
ciple, analogous  to  atropine  and  pos- 
sessed of  mydriatic  properties,  is  obtained 
from  the  mother-liquor,  after  atropine 
has  crjrgtallized  out,  which  is  called 
"belladonnine,"  the  latter  being  an 
amorphous,  brown,  varnish-like  mass, 
freely  soluble  in  chloroform  and  slightly 
soluble  in  water.  Atropine  is  used  in 
all  cases  where  is  desired  an  immediate 
and  rapid  action,  as  when  a  patient  can- 
not swallow,  and  when  the  stomach  will 
not  tolerate  belladonna  or  its  prepara- 
tion. Belladonna  and  its  preparations 
are  preferred  when  a  slow  and  more  con- 
tinuous action  is  desired. 

Dose  and  Physiological  Action. — The 
dose  of  belladonnae  foliorum  is  1  to  5 
grains.  Of  belladonnEe  radix  from  1  to 
3  grains  may  be  given.  The  extractum 
belladonnag  foliorum  is  given  in  doses  of 
Vio  to  V4  grain.  The  dose  of  extractum 
belladonnag  radicis  fluidum  is  from  1  to 
3  minims,  and  of  the  tinctura  bella- 
donnas foliorum  is  from  5  to  15  minims. 
The  physiological  action  of  belladonna 
has  been  already  described  in  the  article 
on  Atropine. 

Belladonna  Poisoning.  —  The  symp- 
toms of  poisoning  by  belladonna  appear 
usually  within  two  hours,  and  are  similar 
to  the  poisonoiTS  effects  of  all  the  solana- 
eeous  plants  (stramonium,  or  thorn- 
apple;  Jamestown  weed;  hyoscyamus,  or 
henbane;  Solanum  dulcamara,  or  bitter- 
sweet; woody-nightshade,  etc.).  The 
characteristic  effects,  stated  briefly  (fuller 
description  has  already  been  given  in 
article  on  Ateopine),  are  frequently 
flushed  face,  redness  of  the  skin,  heat 
and  dryness  in  the  throat,  dilatation  of 
the  pupil,  sensory  illusions,  and  active 
delirium.  Death,  when  it  occurs,  xtsu- 
ally  takes  place  within  twenty-four  hours. 
A    few   berries   of  belladonna    and    one 


drachm  of  the  extract  have  prove  fatal. 
The  post-mortem  appearances  are  not 
constant  or  well  marked.  The  pupils  are 
dilated.  The  brain  may  be  congested  and 
the  stomach  inflamed.  The  remains  of 
the  leaves  or  berries  should  be  searched 
for  in  the  stomach  and  intestines. 

Incompatibility  or  antagonism  of  the 
coal-tar  preparations  and  any  forms  of 
belladonna  noted.  If  either  is  being 
taken  and  the  other  is  given,  delirium  is 
produced  at  once.  Several  cases  observed 
with  the  same  result.  J.  R.  Nelms  (Med. 
Brief,  Feb.,  '98). 

Effect  of  belladonna  upon  the  human 
vision  was  considered  in  a  libel  suit  re- 
cently reviewed  by  Appellate  Division  of 
the  Supreme  Court  at  Albany,  New  York. 
The  plaintiff  was  a  physician  who  treated 
the  defendant's  daughter  for  some  ail- 
ment of  the  eyes,  and  in  the  course  of  the 
treatment  administered  belladonna.  The 
girl  subsequently  became  blind,  and  her 
father  attributed  the  loss  of  her  eyesight 
to  the  unskillfulness  of  the  plaintiff  and 
his  ignorance  in  giving  her  belladonna 
and  thus  producing  her  blindness.  The 
doctor  sued  him  for  libel  for  publishing 
statements  of  this  purport.  Every  med- 
ical witness  testified  that  belladonna 
would  not,  and,  indeed,  could  not,  cause 
blindness  in  any  person.  They  all  agreed 
that  the  drug  produced  a  dilation  of  the 
pupil,  accompanied  by  a  partial  loss  of 
vision,  but  that  this  was  only  temporary 
and  the  effect  would  gradually  pass 
away.  Proof  on  this  point  was  so  clear 
and  conclusive  as  to  leave  no  doubt  in 
the  mind  of  the  Appellate  Court  that 
the  unhappy  father  was  mistaken  in 
holding  the  doctor  responsible  for  the 
misfortune  of  his  child.  Editorial  (Med. 
Standard,  May,  '98). 

Case  of  belladonna  poisoning  after  the 
administration  of  a  2-grain  belladonna 
pessary  in  a  woman  aged  62  years.  In 
attempting  to  administer  some  medicine 
with  a  spoon  she  started  violently  at  the 
mnment  the  spoon  touched  her  lips.  The 
approach  of  a  candle  in  order  to  study 
the  reaction  of  the  pupils  gave  the  same 
result.  Her  face  Avas  much  congested. 
There    was   no   stertor.     This    condition 


550 


BELLADONNA.     POISONING.     TREATMENT.     THERAPEUTICS. 


continued  for  almost  twelve  hours,  after 
which  she  awakened  with  a  slight  head- 
ache, but  without  any  recollection  of 
what  had  transpired.  Reuell  Atkinson 
(Brit.  Med.  Jour.,  Feb.  25,  '99). 

Case   in   which   there    occurred   symp- 
toms of  belladonna   poisoning  after  the 
application,  to  the  back,  of  an  ordinary 
perforated  belladonna  plaster.     Prior  to 
its  application  the  skin  had  been  freely 
rubbed    with    a    towel.      H.    Aldersmith 
(Brit.  Med.  Jour.,  May  27,  '99). 
Treatment  of  Belladonna  Poisomng. — 
The   treatment   of   poisoning   by   bella- 
donna is  the  same  as  that  outlined  for 
atropine  poisoning:    Evacuation  of  the 
stomach   by   emetics   or  stomach-pump. 
Morphine   (^/g  to   V2  grain)   should  be 
given  hypodermically,  repeated  at  inter- 
vals  according   to   the   urgency   of  the 
symptoms  and  the  response  to  the  rem- 
edy.    Pilocarpine   (Vs  to  ^A  grain)   or 
eserine  (V200  fo  Vso  grain)  may  be  used 
in  the  same  manner.    When  the  patient 
shows  signs  of  improvement,   castor-oil 
may  be  given  to  evacuate  the  bowels  and 
remove  any  remaining  particles  of  the 
poisonous  leaves,  berries,  or  root.   Strong 
coffee  and  alcohol  are  tiseful  agents  if 
the  patient  is  conscious  and  can  swallow. 
Case   of   a   woman    confined    three   or 
four  days  before.     Found  a  slight  rash 
all  over  the  body,  which  had  the  appear- 
ance   of    measles,    and    somewhat    cres- 
centic  in  character;    temperature  a  little 
over  101°.     On  inquiry  learned  an  oint- 
ment  containing   extract   of   belladonna 
was  being  used  on  breasts  with  a  view 
to   getting  rid  of  her  milk.     It  was  a 
belladonna     rash.       Have     seen     several 
cases  of  belladonna  poisoning  from  the 
local  application  of  belladonna  liniment. 
Campbell    (Montreal    Med.    Jour.,    Dec, 
'96). 

Case  of  a  man,  aged  45,  who  took,  on 
nn  empty  stomach  at  5.30  a.m.,  a  little 
over  an  ounce  of  glycerinum  belladonnse: 
tlie  equivalent  of  about  3  grains  of 
atropine.  Treated  by  apomorphine, 
strj'chnine,  and  morphine  suboutane- 
ously.     Recovery  occiirred  after  tAventy- 


four  hours.     There  was  no  maniacal  ex- 
citement,  but   delirium  and   coma;     the 
first  prominent  symptom  was  muscular 
ineo-ordination.     The  experiments  of  the 
Edinburgh   committee  go  to  show   that 
morphine  is  not  antagonistic  to  atropine, 
although  atropine  is  to  morphine;    but 
one   or  two   cases  are   on   record   where 
morphine  by  subcutaneous  injection  re- 
lieved the  symptoms  of  atropine  poison- 
ing.    One  case  is  specially  mentioned  by 
Binz  where  a  boy  had  eaten  the  seeds  of 
Datura     stramonium,    the    alkaloid    of 
which  is  in  many  respects  identical  with 
atropine.     In  this  case  death  seemed  in- 
evitable, and  as  a  last  resource  morphine 
Avas  administered,  with  the  result  that 
the  grave  symptoms  were  arrested,  and 
the  boy  speedily  recovered.     In  the  case 
just    recorded   there   seemed    to   be    un- 
doubtedly   great    benefit    derived    from 
morphine,   as  the   delirium   and  halluci- 
nations    subsided     almost    Immediately, 
and  remained  permanently  in  abeyance. 
Duncan   (Brit.  Med.  Jour.,  May  8,  '97). 
Therapeutics.  —  Gasteo-Intestinal 
DiSORDEHS. — Mercurial  ptyalism  and  the 
ptyalism  of  pregnancy  may  be  relieved 
by  the  tincture  of  belladonna  given  in 
doses  of  5  to  10  drops  every  four  to  six 
hours.     Gastralgia  and  the  pain  of  gas- 
tric   ulcer    are    relieved    by    atropine. 
Bartholow  suggests  the  following: — 

IJ   Atropine  sulph.,  Vg  grain. 
Zinc  sulph.,  30  grains. 
Distilled  water,  1  ounce. — M. 
From  3  to  5  drops  twice  or  thrice  a 
day. 

He  recommends  a  similar  combina- 
tion as  very  effective  in  pyrosis,  chronic 
gastric  catarrh,  and  irritative  dyspepsia. 
Vomiting  of  pregnancy  may  be  relieved 
by  the  internal  administration  of  V120 
grain  of  atropine  sulphate,  in  water,  be- 
fore meals;  if  the  stomach  is  irritable, 
the  atropine  may  be  given  in  supposi- 
tor}',  or,  dissolved  in  chloroform  (1  to 
96),  it  may  be  used  on  lint  applied  to 
the  epigastrium.     Habitual  constipation 


BELLADONNA.  THERAPEUTICS. 


551 


may  be  relieved  by  Vo  to  V^  grain  of 
the  extract  in  pill,  taken  at  bed-time. 
(Trousseau.) 

Added  to  other  purgatives  it  dimin- 
ishes their  griping  action,  and,  since  it 
increases  peristalsis  and  allays  spasm,  it 
increases  their  efficiency.  When  there 
exists  a  torpor  of  the  lower  bowel  aloin 
is  a  valuable  addition.  An  excellent 
combination  is 

19   Aloin, 

Ext.  nux  vomica, 

Resin    podophyllin,    of    each,    V2 

grain. 
Ext.  belladonna,  V^  grain. 

Make  2  pills.  One  or  two  at  bed-time. 
Heart-burn  and  water-brash  may  be  re- 
lieved by  atropine  (^Ago  grain)  combined 
with  5  drops  of  dilute  muriatic  acid,  well 
diluted  and  taken  before  meals. 

Fevers.  ■ —  Belladonna  has  been  used 
with  good  results  in  typhus  and  typhoid 
fevers.  Graves  suggested  that  the  con- 
tracted pupil  was  an  indication  for  its 
use.  Bartholow  advises  it  when  there 
is  much  low,  muttering  delirium,  sub- 
siTltus,  and  stupor,  but  cautions  against 
its  use  in  the  condition  of  delirium  ferox. 
The  tincture  may  be  used  in  doses  of 
from  5  to  10  drops  every  four  hours. 

Disorders  of  the  Aie-passages.  — 
Acute  coryza  may  be  aborted  through 
the  use  of  the  tincture  of  belladonna, 
5  drops  being  given  at  first  and  1  or  2 
drops  every  succeeding  hour,  until  the 
physiological  effects  are  produced.  In 
pharyngitis  with  increased  secretion  sim- 
ilar treatment  is  efficient;  if  there  is 
much  fever  1  drop  of  tincture  of  aconite 
with  2  drops  of  tincture  of  belladonna 
may  be  given  every  hoxir  or  two.  Apho- 
nia, due  to  fatigue  of  the  vocal  cords, 
may  be  removed  very  speedily  by  a  morn- 
ing and  evening  dose  C/i^o  to  ^/go  grain) 
of  atropine;  hysterical  aphonia  may,  not 


infrequently,   be   quickly   cured   in   the 
same  way.    (Bartholow.) 

I  have  long  regarded  the  mucous  ex- 
pectoration in  bronchitis,  whether  viscid 
and  vitreous  or  profuse  and  watery,  as 
rather   an   increased   secretion    than    an 
inflammatory  product,  and  this  view  is 
supported  by  the  promptness  with  which 
tincture  of  belladonna,  in  10-minim  doses 
thrice   daily   or   oftener,   checks   the   se- 
cretion   and    relieves    an    incessant    and 
troublesome  cough.     By  this  e.xperience 
I  have  been  led  to  administer  belladonna 
in  cases  of  bronchitis  following  ether  in- 
halation, and,  although  my  cases  are  few, 
yet   the    success    has    been    sufficient,    I 
think,  to  draw  attention  to  this  treat- 
ment, that  others  with  more  opportuni- 
ties may  test  the  efKcacy  of  belladonna. 
I    would    also    suggest   that    belladonna 
should  be  given  to  patients  who,  after 
aspiration,     suffer     from     an     abundant 
A^atery   expectoration,   so  profuse   some- 
times as  to  kill  by  suffocation.     Sydney 
Einger   (Brit.  Med.  .Jour.,  Nov.  21,  '96). 
SrASiiODic  Disorders. — In  pertussis 
belladonna  may  be  considered  one  of  the 
most  reliable  remedies.     As  Bartholow 
suggests,  it  is  not  adapted  to  all  cases, 
but  is  most  effective  in  the  spasmodic 
stage  and  in  those  cases  which  are  char- 
acterized by  profuse  bronchial  secretion. 
He  recommends  an  aqueous  solution  of 
atropine  sulphate  (1  to  480),  giving  2  to 
i  drops  at  a  dose.     The  tincture  of  bel- 
ladonna may  be  given  in  doses  of  from 
3  to  5  minims  every  three  or  four  hours, 
stopping  when  there  is  a  perceptible  dila- 
tation of  the  pupils,  or  even  slight  red- 
dening of  the  skin.    The  dryness  of  the 
throat  and  mouth  may  be  relieved  by 
small  doses  of  the  iodides,  by  small  doses 
of  wine  of  ipecac  or  antimonial  wine,  by 
occasional  small  doses  of  calomel,  or  by 
ammonium    chloride.      Westbrook   sug- 
gests the  following: — 

T^   Tinct.  belladonna,  3  to  5  minims. 
Alum,  1  drachm. 
Syrup  of  Tolu,  1  ounce. 
Water,  2  ounces. — M. 


552 


BELLADONNA.     THERAPEUTICS. 


Of  this  mixture  the  child  may  be  given 
a  teaspoonful  every  two  or  three  hours, 
day  and  night,  if  it  is  awake.  When  the 
spasm  is  marked  and  very  frequent,  the 
following  is  used: — 

^  Tinct.  belladonna,  3  minims. 

Tinct.  camphorated  opium,  2  to  4 

drachms. 
Muriate  of  ammonium,  1  drachm. 
Bromide       of       ammonium,       2 

drachms. 
Syrup  of  wild  cherry-bark,  enough 

to  make  3  ounces. — M. 

Of  this  a  teaspoonful,  diluted,  is  given 
every  two  or  three  hours,  night  and  day, 
if  the  child  is  awake.'  Forchheimer  ad- 
vocates the  use  of  quinine  in  conjunc- 
tion with  belladonna. 

In  pertussis,  when  a  complication  of 
measles,  belladonna  pushed  to  its  physi- 
ological effects  acts  well.  Bemardy 
(Annals  of  Gj'n.  and  Paed.,  July,  '94). 

Belladonna  per  se  will  relieve  pertussis. 
The   younger  the   child,   the   better   the 
drug   acts.     It   takes   proportionately   a 
larger  dose  to  produce  toxic  symptoms 
in  a  child  than  in  an  adult.     The  drug 
is  given  every  hour  unless  marked  dila- 
tion of  the  pupils  is  produced.     Garrison 
(Med.  News,  June   12,  '97). 
In  asthma  and  in  the  dyspnoea  which 
accompanies    emphysema    belladonna 
gives  great  relief.     According  to  Bar- 
tholow's    observations,   when   the   bron- 
chial   secretion    is    deficient,    the    pulse 
much  accelerated,  and  the  skin  dry  and 
hot,  belladonna  adds  to  the  distress;   its 
good  efEficts  are  noticed  when  the  expec- 
toration is  abundant,  the  skin  cool  and 
moist,  and  the  pulse  quiet  and  of  low 
tension.    For  the  relief  of  the  paroxysm 
the  hypodermic  administration  of  atro- 
pine, or  of  atropine  and  morphine  com- 
bined, is  to  be  preferred  to  medication 
by  the  stomach,  as  the  latter  is  too  slow. 
After  the  paroxysm  is  relieved,  the  effect 
may  be  prolonged  by  internal  medica- 


tion. Belladonna-leaves  may  be  used  by 
the  method  of  fumigation.  The  leaves 
previously  dipped  in  a  saturated  solution 
of  nitre  and  then  dried  may  be  burned 
in  a  close  apartment,  or  on  a  saucer,  the 
fumes  being  inhaled  from  a  paper  fun- 
nel covering  the  same.  Pastilles  made 
of  belladonna,  stramonium,  poppy,  to- 
bacco, etc.,  may  be  used.  Trousseau 
gives  a  formula  for  asthmatic  cigar- 
ettes:— 

J^   Belladonna-leaves,  5  grains. 
Stramonium-leaves, 
Plyoscyamus-leaves,     of     each,     3 

grains. 
Extract  of  opium,  ^/j  grain. 
Cherry-laurel    water,    a    sufficient 

quantity. 

The  leaves  are  moistened  with  a  solu- 
tion of  the  opium  in  the  cherry-laurel 
water,  and  when  dry  made  into  a  cigar- 
ette. Two  to  four  such  cigarettes  may 
be  smoked  daily. 

A  person  liable  to  attacks  of  asthma 
should  be  classed  with  those  who  have 
fits  of  epilepsy  and  occasional  attacks 
of  sick  headache.  They  have  unstable 
nerve-centres,  likely  to  explode  their 
energies  at  any  moment,  and  exhibit 
the  pathological  phenomena  peculiar  to 
nerve-storms.  Treatment  should  be  di- 
rected to  break  up  this  habit  morbidly 
acquired  by  the  nerve-centres,  and  by 
prolonged  medication  to  maintain  the 
centres  in  a  state  of  more  stable  equi- 
librium. This  is  done  very  successfully 
in  epilepsy,  and  can  also  be  done  in 
asthma.  I  give,  for  this  purpose,  chlo- 
ral and  belladonna  night  and  morning, 
or,  at  least,  at  bed-time,  and  find  that, 
after  a  time,  the  attacks  diminish  in  fre- 
quency and  lessen  in  severity.  Pearse 
(Practitioner,  Jan.,  '93). 

Belladonna  is  useful  in  the  treatment 
of  spasmodic  cough  and  in  spasmodic 
croup,  given  between  the  paroxysms; 
more  rapid  measures  are  needed  for  the 
relief  of  the  paroxysm  itself. 


BELLADONNA.  THEEAPEUTICS. 


553 


In  the  treatment  of  nocturnal  incon- 
tinence of  urine,  no  single  remedy  has 
given  such  good  and  uniform  results  in 
suitable  cases  as  belladonna.  This  dis- 
tressing ailment  may  be  caused  by  hyper- 
acidity of  the  urine,  relaxed  condition  of 
the  sphincter  vesicae,  or  to  an  irritable 
condition  of  the  vesical  mucous  mem- 
brane; belladonna  gives  prompt  relief  in 
the  two  last-named  conditions.  In  male 
children  phimosis,  accompanied  often  by 
adhesion  of  the  prepuce  to  the  glans 
penis  and  retained  smegma,  is  a  frequent 
cause  of  incontinence;  in  these  cir- 
cumcision, and  not  belladonna,  is  indi- 
cated. Again,  the  presence  of  ascarides 
may  be  sufficient  to  cause  nocturnal  in- 
continence, especially  in  female  infants 
and  children;  here  again  belladonna  is 
of  no  avail.  In  suitable  cases,  as  indi- 
cated above,  atropine,  in  solution  or  in 
tablets,  is  best  suited  for  internal  admin- 
istration. Beginning  with  a  small  dose, 
at  bed-time,  the  dose  is  gradually  in- 
creased until  systemic  effects  are  pro- 
duced. It  must  be  remembered  that  as 
regards  children  generally  too  little  of 
the  drug  is  given.  After  the  relief  or 
cure  of  incontinence  the  best  results  are 
obtained  by  continuing  the  use  of  the 
drug  for  several  weeks,  in  diminishing 
doses,  with  an  occasional  intermission  of 
one  to  three  days,  during  which  time  it 
is  not  given.  This  advice  holds  good  in 
treating  spasmodic  disorders  generally. 

In  spasmodic  conditions  of  the  rectum 
associated  with  fissure,  hemorrhoids,  can- 
cer, chronic  constipation,  etc.,  a  small 
suppository  (6  to  10  grains),  containing 
from  ^/^  to  ^/a  grain  of  the  extract,  in- 
troduced well  up  into  the  rectum  beyond 
the  internal  sphincter,  gives  great  relief. 

In  intestinal  obstruction  and  strangu- 
lation I  have  known  relief  to  follow 
elevation  of  the  pelvis  on  a  firm  pillow 
?o  as  to  allow  gravity  to  act  toward  the 


thorax;  and  with  this  treatment,  com- 
bined with  starvation,  and  the  use  of 
belladonna  and  opium,  I  have  had  cases 
of  natural  recovery.  Belladonna  may  be 
used  externally  also  with  glycerin,  and 
in  suppository  with  gelatin.  Thomas 
Bryant  (Lancet,  Jan.  17,  '91). 

In  volvulus  belladonna  employed  with 
opium  in  full  doses  until  constitutional 
effects  shown,  for  peristaltic  paralysis 
due  to  tympanites  or  faecal  accumulation. 
May  be  combined  with  calomel.  Sodium 
sulphate  in  houi'ly  doses  of  1  to  2 
drachms.  Lavage-tube  for  bowel-flush- 
ing. Stokes  (N.  Y.  Med.  Jour.,  No.  1778,  , 
•95). 

In  lead  colic,  whether  due  to  direct 
excitation  of  the  intestinal  ganglia  or 
of  the  abdominal  fibres  of  the  vagus,  or 
to  simple  accumulation  of  hard  and  dry 
faeces  in  the  intestine,  from  reflex  action 
upon  the  contraction  of  smooth  muscular 
fibres  consecutive  to  primary  irritation 
of  the  sensory  nerv-es,  belladonna  or  its 
alkaloid,  by  diminishing,  more  or  less 
completely  and  in  difi'erent  degrees,  the 
irritability  of  the  peripheral  nervous 
apparatus,  takes  away  an  indispensable 
factor  Avhereby  abnoi-mal  stimuli  operate 
through  the  nerves  in  increasing  the 
contractility  of  the  smooth  muscular 
fibres.  Traversa  (II  Policlinico,  No.  24, 
■97). 

In  pelvic  affections  of  women,  at- 
tended by  hyperffimia,  pain,  and  spasm, 
a  larger  suppository  (30  to  60  grains), 
containing  from  ^A  to  1  grain  of  the 
solid  extract,  may  be  introduced  high  up 
within  the  vagina  and  retained  by  means 
of  a  tampon  of  non-absorbent  cotton,  at 
night;  in  the  morning  a  hot-water  vag- 
inal douche  will  add  to  the  comfort  and 
well-being  of  the  patient. 

In  dysmenorrhcea,  belladonna  given 
with  the  advent  of  pain  relieves  by  re- 
laxing the  spasms.  Handfield-Jones 
(Brit.  Med.  Jour.,  May  27,  '93). 

Epilepsy.  —  Belladonna,  according  to 
Trousseau  and  Pidoux,  is  a  more  effi- 
cient remedy  in  the  treatment  of  epi- 
lepsy  than   the   salts   of   silver,   copper. 


654 


BELLADONNA.     THERAPEUTICS. 


or  zinc.  Both  insist  that  belladonna 
shonld  be  given  steadily  for  a  year  in 
gradually  increasing  doses,  and  that  if 
amendment  is  then  produced  it  should 
be  continued  through  two,  three,  or 
even  four  years.  The  best  results  from 
the  use  of  belladonna  are  obtained  in 
nocturnal  epilepsy,  in  petit  mal,  and  in 
pale,  delicate,  and  ancemic  subjects,  with 
cold  hands  and  feet,  blue  skin,  and  weak 
heart  (Bartholow).  Nothnagel  advises  a 
combination  of  zinc  oxide  with  the  bella- 
donna, the  former  in  gradually  increas- 
ing doses.  Moeli  has  advised  an  alterna- 
tion of  atropine  and  bromides  as  very 
effective,  on  the  analogy  of  the  opium- 
bromide  treatment.  Belladonna  is  not 
equal  to  the  bromides  in  diurnal  epi- 
lepsy, in  epilepsy  accompanied  by  cere- 
bral hyperemia,  or  in  epileptiform  con- 
vulsions due  to  an  organic  lesion  of  the 
brain.  More  effectual  than  the  atropine 
is  Trousseau's  method:  During  the  first 
month  the  patient  takes  a  pill — com- 
posed of  extract  of  belladonna  and  pow- 
dered leaves  of  belladonna,  of  each,  ^/^ 
grain — every  day,  if  his  attacks  occur 
chiefly  in  the  day-time;  or  in  the  even- 
ing, if  they  are  chiefly  nocturnal.  One 
pill  is  added  to  the  dose  every  month; 
and,  whatever  be  the  dose,  it  is  always 
taken  at  the  same  time  of  the  day.  The 
dose  may  thus  be  increased  from  5  to  20 
pills  or  more.  If  this  treatment  fails  to 
cure,  it  yields  much  relief. 

Belladonna  may,  in  grave  cases  of 
epilepsy,  bring  about  a  prolonged  sus- 
pension of  attacks  analogous  to  that 
produced  by  bromides.  Fere  (Journal 
des  Connaissances  Med.  Prat,  et  de 
Pharm.,  Nov.  21,  '95). 

Cerebeo-Spinal  Disorders. — Bella- 
donna and  atropine  have  been  found  use- 
ful in  the  treatment  of  epidemic  cerebro- 
spinal meningitis,  the  basilar  meningitis 
of  children,  and  the  various  acute  forms 


of  myelitis,  etc.  In  cerebro-spinal  men- 
ingitis, in  which,  so  long  as  conscious- 
ness ■  exists  if  there  is  great  pain,  the 
addition  of  opium  or  morphine  to  the 
belladonna  or  atropine  increases  its 
efficacy. 

Keuralgia. — The  ointment  or  plaster 
of  belladonna  is  a  useful  application  in 
neuralgia  of  various  forms  (mammary, 
intercostal,  cervico-dorsal,  etc.).  A  few 
drops  of  aconite  used  to  moisten  the  sur- 
face of  a  belladonna  plaster  before  ap- 
plying will  in  most  cases  increase  its 
efficiency.    (See  Atropine.) 

Miscellaneous. — Belladonna  has 

also  been  recommended  in  a  variety  of 

disorders     other     than    the     foregoing, 

prominent    among    which    are    cystitis, 

hysteria,  migraine,  and  angina  pectoris. 

In   acute   cystitis   the   first   indication 

in  treatment  is  to  allay  tenesmus   and 

pain.     The  foUoAving  suppository  should 

be  used  every  four  hours:  — 

IJ  Morphine  muriate. 

Cocaine  hydroehlorate,  of  each,  V» 

grain. 
Extract  of  belladonna,  V12  grain. 
Cocoa-butter,  46  grains. 

In  hysteria  in  children  belladonna,  in 
doses  of  Vo  grain  of  the  extract,  is  useful, 
especially  for  the  visceral  pains.  Simon 
(Med.  and  Surg.  Reporter,  May  5,  '94). 

In  women  the  topical  application  may 
be  in  the  vagina,  as  it  combats  the  cys- 
titis of  the  neck.  Lutaud  (Jour,  de 
Med.,  July  22,  '94). 

In  order  to  obtain  the  desired  effect 
from  belladonna,  very  small  doses  should 
be  given  at  frequent  intervals.  When 
given  in  this  manner  in  fevers,  or  hyp- 
odermically  in  cholera  infantum  and 
pernicious  intermittents,  it  has  proved 
a  most  valuable  remedy.  As  a  stimu- 
lant to  the  respiratory  nerve-centres  it 
has  a  place  in  pneumonia,  and  in  enu- 
resis it  gives  excellent  results,  if  the 
doses  are  increased  until  a  toxic  effect 
is  obtained.  To  augment  peristalsis,  it 
should  be  used  in  suspected  ffecal  or 
mechanical     obstruction     of    the     bowel. 


BELLADONNA.  THERAPEUTICS. 


555 


In  the  so-called  spurious   hj'drocephalus 
it  is   beneficial  in  maintaining   cerebral 
vitality.     I  have  many  times  by  its  use 
averted    coma    in    typhoid    fever    after 
Cheyne-Stokes   respiration    was   present. 
Larrabee   (Pediatrics,  Sept.  1,  '96). 
In  angina  pectoris  Massy  extols  bella- 
donna or  its  alkaloid,  but  Huchard  de- 
nies any  good  effects  and  adds:   "It  dis- 
turbs the  mechanism  of  the  heart  and 
contracts  the  arteries,"  which  seems  most 
tenable,  being  in  line  with  the  known 
physiological  action  of  the  drug. 

Cutaneous  Disorders. — Belladonna 
is  useful  in  certain  affections  of  the  skin, 
in  the  cutaneous  neuroses,  prurigo, 
herpes  zoster,  erythema,  and  eczema. 
Sufficiently  large  doses  to  maintain  a 
mild  physiological  action  must  be  used. 
Hyperidrosis  and  unilateral  sweating 
are  arrested  by  the  internal  or  by  the 
local  application  of  the  belladonna  prep- 
arations. 

[The  use  of  atropine  in  relieving  the 
sweats  of  phthisis  has  been  referred  to 
under  Atropine. — Ed.] 

In  doses  of  from  -/13  to  'A  grain  of  the 
extract,  belladonna  is  the  best  remedy 
in  chronic  urticaria,  which  appears  to 
be  due  to  an  acute  oedema  of  the  con- 
nective tissue  of  the  skin  as  the  result 
of  active  vasomotor  dilatation.  Liggeois 
(Eevue  Med.  de  I'Est,  Nov.   15,  '90). 

For  the  pruritus  of  lichen,  fractional 
doses  of  tincture  of  belladonna;  give  1 
to  4  drops,  three  times  a  day.  If  an 
urticarial  element  exists,  quinine  with 
ergotine  may  be  used  where  belladonna 
fails.  Brocq  (Gaz.  des  Hop.,  Feb.  20, 
'92). 

In  a  case  of  pemphigus,  in  a  boy  aged 
15  years,  3  drops  of  tincture  of  bella- 
donna, three  times  a  day  were  given; 
at  the  end  of  a  week  increased  to  4 
drops.  Decided  improvement  now  set  in, 
and  for  about  a  week  no  new  vesicles 
formed.  A  few  new  blisters  then  ap- 
peared, and  the  belladonna  was  increased 
up  to  6  drops  three  times  daily.  One 
of  the  best-known  actions  of  belladonna 
is  its  power  of  controlling   perspiration. 


and  in  doing  this  it  put  the  lad's  feet 
in  the  same  condition  in  this  regard  in 
summer    as     in     winter.       Montgomery 
(Med.  News,  Nov.  16,  '95). 
External  Uses.  —  Belladonna  used 
externally  (liniment,  ointment,  or  plas- 
ter of  belladonna;    or  atropine)  in  solu- 
tion  is   of  value   in  the   treatment   of 
swollen   lymphatic,   parotid,    and   other 
salivary  glands  and  the  mammae.    It  may 
be    applied    over   sprained    or    inflamed 
joints.     The  application  of  a  mild  sin- 
apism, to  redden  the  skin  slightly,  will 
increase  the  efficiency  of  the  belladonna. 
In  blepharospasm  the  extract  or  oint- 
ment may  be  rubbed  on  to  the  eyelids 
externally. 

In  recent  typhlitis  with  acute  exacer- 
bations give  full  warm  baths,  lasting  half 
an  hour;  every  hour  a  teaspoonful  of  a 
purgative  mixture  made  up  of  1  part 
each  of  castor-oil  and  oil  of  sweet 
almonds  and  2  parts  of  syrup  of  lemon, 
until  active  purgation  is  established; 
mercury  and  belladonna  ointment  over 
the  csecum;  and  then  hot  linseedmeal 
poultices.  For  recurrent  typhlitis  there 
should  be  treatment  in  the  intervals  with 
a  diet  that  leaves  little  residue,  and  with 
counter-irritation  and  belladonna  oint- 
ment over  the  caecum,  the  bowels  being 
kept  regulated  and  intestinal  antiseptics 
administered.  Grasset  (Eevue  Ggn.  de 
Clin,  et  de  Ther.,  Dec.  6,  '93). 

In  ileus  apply  a  compress  of  fifty 
square  ■  centimetres  [about  three  inches 
square,  Ed.]  coated  with  belladonna 
extract  mixed  with  a  little  vaselin.  If, 
some  hours  after  this  application,  symp- 
toms of  atropinism  supervene,  an  enema 
of  ox-gall  is  given,  which  often  relieves 
intestinal  obstruction.  In  appendicitis, 
after  the  acute  period,  a  compress  eight 
by  three  inches,  coated  with  extract  of 
belladonna  and  potassium  iodide,  of  each, 
1  drachm;  lard,  1  ounce,  is  usefvil;  the 
action  of  potassium  iodide  on  the  skin 
promotes  the  absorption  of  the  bella- 
donna extract  contained  in  the  ointment. 
A  suppository  containing  1  grain  of 
belladonna  extract  should  also  be  used 
everv  eight  hours.     As  soon  as  the  first 


556 


BENZOIC  ACID.     PHYSIOLOGICAL  ACTION. 


symptoms  of  intoxication  appear,  a  soap 
enema  with  ox-gall  and  sodium  carbon- 
ate should  be  administered;  this  pro- 
duces a  copious  and  easy  stool  without 
irritating  the  affected  intestine.  Byers 
(American  Medico-Surg.  Bull.,  Jan.  15, 
'94). 

C.    SUMNEE    WiTHEESTINE, 

Philadelphia. 

BENZOIC  ACID.  —  Benzoic  acid  is  a 
peculiar  principle  and  is  had  from  many 
different  sources.  It  is  made  by  oxida- 
tion of  toluene  with  nitric  acid,  which 
is  the  most  common  form.  It  is  derived, 
also,  from  the  different  benzoins,  Asiatic 
and  American;  from  urine,  etc.  The 
best,  however,  is  that  made  from  Siamese 
benzoin,  technically  known  as  pheni- 
formic  acid,  and  presents  white,  pearly 
plates  or  needles,  though  with  age  and 
exposure  to  light  it  sometimes  acquires 
a  slight-yellowish  tinge.  It  possesses  an 
agreeable  aromatic  odor  and  taste,  and 
is  soluble  in  the  proportions  of  1  to  500 
in  cold  and  1  to  15  in  boiling  water; 
1  to  2  in  alcohol;  1  to  3  in  ether;  1  to 
7  in  chloroform;  1  to  10  in  glycerin. 
Borax  or  sodium  phosphate  increases  its 
solubility  in  water.  "With  different  bases 
it  forms  very  soluble  salts. 

Preparations  and  Doses.  —  Benzoic 
acid,  10  to  30  grains. 

Benzoate  of  ammonium,  10  to  30 
grains. 

Benzoate  of  bismuth,  10  to  20  grains. 

Benzoate  of  calcium,  6  to  15  grains. 

Benzoate  of  iron,  2  to  6  grains. 

Benzoate  of  lithium,  15  to  30  grains. 

Benzoate  of  mercury,  for  external  use 
only. 

Benzoate  of  potassium,  5  to  20  grains. 

Benzoate  of  sodium,  30  to  120  grains. 

Benzoate  of  zinc,  for  external  use  only. 

Physiolog^ical  Action. — -Externally 
benzoic  acid  and,  in  less  degree,  its  salts 
are  irritant,  and  the  vapors  when  inhaled 


tend  to  bronchial  irritation  and  catarrhal 
inflammation.      Internally   administered 
in  ordinary  therapeutic  doses  it  exerts 
no  untoward  effects  except,  perhaps,  to 
provoke  a  moderate  amount  of  gastric 
irritation  with  resultant  nausea  and  vom- 
iting.    Sometimes  there  is  acceleration 
of  the  heart's  action  and  of  respiration. 
Schreiber  took  in  two  days  about  Vi 
ounce  of  the  acid,  and  experienced  only 
a  feeling  of  abdominal  warmth,  spread- 
ing  over   the   whole   body,    and    accom- 
panied by  an  increase  of  the  pulse-rate 
amounting  to  30  beats  per  minute;    also 
increased     reaction     and     excretion     of 
phlegm,  with  slight  disturbances  of  di- 
gestion.    H.   C.  Wood    ("Principles  and 
Practice  of  Therapeutics,"  ninth   ed.). 

Benzoic  acid  and  the  benzoates  are 
eliminated  mainly  by  the  kidneys,  partly 
as  benzoic  acid,  but  chiefly  as  hippuric 
acid.  The  exact  method  by  which  the 
latter  acid  is  produced  constitutes  one 
of  the  great  problems  of  physiological 
chemistry,  though  the  change  is  gener- 
ally presumed  to  take  place  in  the  kid- 
neys; certainly  it  does  not  happen  in  the 
intestines  or  in  the  blood. 

The  benzoates  generally,  yet  in  less 
degree,  evince  much  the  same  action  as 
the  acid.  The  ammonium  salt  borrows 
from  its  base  a  neutralizing  action  upon 
acids  and  increases  the  activity  of  the 
kidneys.  Benzoate  of  bismuth  resembles 
other  salts  of  the  same  base.  Calcium 
benzoate,  as  might  be  expected,  com- 
bines in  a  measure  the  action  of  both 
base  and  acid.  As  it  is  unofficial,  and 
in  little  use  or  reiDute,  it  demands  no 
further  mention.  The  same  remarks 
practically  apply  also  to  the  iron  salt. 
The  lithia  salt  is  supposed  to  possess  a 
special  affinity  for  uric  acid  and  urea, 
dissolving  the  one  and  eliminating  the 
other,  but  the  claims  made  in  this  direc- 
tion are  by  no  means  substantiated.  It 
is  eliminated  by  the  kidneys  the  same 


BENZOIC  ACID.     THERAPEUTICS. 


557 


as  benzoic  acid,  but  more  frequently 
yields  succinic  instead  of  hippuric  acid: 
a  phenomenon  that  is  most  piizzling. 
Potassium  benzoate  presents  nothing 
from  a  physiological  stand-point  that 
does  not  accrue  to  other  salts,  except  it 
is  more  difficult  of  elimination  than  the 
sodium  salt;  the  latter  most  closely  re- 
sembles the  acid  in  its  action,  but  is 
more  readily  absorbed  and  more  con- 
tinuous in  its  effects. 

Therapeutics.  —  Benzoic  acid  exter- 
nally employed  is  an  antiseptic  of  con- 
siderable value,  and  both  benzoate  of 
bismuth  and  benzoate  of  zinc  have  been 
lauded  and  exploited  in  connection  with 
surgical  dressings.  All  are  practically 
unobjectionable  and  devoid  of  unpleas- 
ant odor;  hence  may  be  made  available 
when  more  acrid  and  unpleasant  agents 
are  inhibited.  Indeed,  there  is  little 
doubt,  in  antiseptic  surgery  benzoic  acid 
might  in  a  majority  of  instances  be  sub- 
stituted for  carbolic  or  salicylic  acid  with 
benefit.  Friar's  balsam — balsamum  trau- 
maticum  of  the  old  pharmacopoeias — 
was  formerly  in  great  repute  as  a  vul- 
nerary, and  the  experiences  of  Mr. 
Bryant,  of  London,  evidences  its  value: 
He,  when  confronted  with  a  compound 
fracture  or  other  severe  wound,  dresses 
with  lint  thoroughly  saturated  with  this 
compound  tincture  of  benzoin  and  main- 
tains absolute  quiet  with  non-removal  of 
dressing  for  several  days;  and  his  results 
challenge  those  obtained  by  the  most 
complicated  antiseptic  dressing.  It  is, 
perhaps,  needless  to  remark  that  the 
value  of  the  tincture,  or  "balsam,"  lies  in 
its  contained  benzoic  acid. 

Internally,  also,  the  acid  is  an  anti- 
septic of  no  mean  value;  the  salts  also 
in  proportion;  though  the  best,  when 
desired  to  exhibit  for  this  purpose  alone, 
is  undoubtedly  the  benzoate  of  bismuth, 
which  contains  about  25  per  cent,  of  the 


acid,  and  if  desired  may  be  given  in  quite 
large  doses,  even  larger  than  those  here 
indicated.  Either  the  acid  or  this  salt 
in  medicinal  doses  is  comparatively  in- 
nocuous. As  an  antipjrretic,  too,  benzoic 
acid  has  won  some  reputation,  and  it  is 
as  infinitely  to  be  preferred  for  this  pur- 
pose over  salicylic  acid  as  are  its  salts 
above  those  of  the  latter. 

In  the  treatment  of  cystitis,  with  alka- 
line or  ammoniacal  urine,  the  acid  has 
won  golden  opinions,  though  here  its 
ammonium  salt  is  generally  preferred  as 
being  more  active  and  less  likely  to  dis- 
turb the  stomach. 

In  conditions  of  urinary  alkalinity 
short  of  phosphatic  cystitis,  ammonium 
benzoate  is  very  beneficial,  the  condition 
of  irritability  of  the  bladder  or  inconti- 
nence of  urine  associated  with  an  alka- 
line imnary  reaction  being  almost  in- 
variably relieved  by  its  administration. 
(Foster.) 

It  is  said  to  sometimes  act  very  hap- 
pily in  acute  gonorrhoea,  but  it  must  be 
admitted  that  it  is  a  somewhat  uncertain 
remedy.  The  bismuth  salt  may,  how- 
ever, substitute  other  bismuth  prepara- 
tions in  preparing  injections. 

Benzoate  of  lithia  is  very  soluble  in 
water  and  has  been  recommended  in 
painful  arthritic  affections  of  the  joints. 
Clement  prefers  it  to  either  the  salic- 
ylate or  carbonate.  It  is  an  excellent 
diuretic,  and  certainly  is  often  useful  in 
the  management  of  chronic  gouty  or 
rheumatic  conditions.  Its  use  has  also 
been  proposed  in  the  management  of 
urfBmic  cases,  while  it  may  be  of  service 
in  relieving  local  manifestations;  in  the 
main,  it  is  not  to  be  depended  upon. 

Benzoate  of  sodium  is  the  most  widely 
employed  of  all  the  salts,  that  of  lithia, 
perhaps,  excepted, — probably,  as  before 
remarked,  because  it  more  nearly  re- 
sembles   benzoic    acid    in    physiological 


558 


BENZOIC  ACID. 


BENZOIN. 


action.      Bucholtz    claims   that   it    even 
surpasses  the  acid  as  an  antizymotie. 

It  is  an  excellent  diuretic  which  stim- 
ulates the  mucous  membranes  in  general, 
except  those  of  the  liver,  and  it  tends 
to  increase  and  promote  organic  ex- 
change. It  is  frequently  indicated  in 
uric  and  hippurie  diatheses,  in  general, 
and  in  gouty  affections.  It  is  to  be 
recommended  equally  in  subacute  and 
chronic  rheumatisms,  and  some  authors 
appear  to  have  employed  it  with  equal 
success  in  acute  rheumatism.  In  the 
chronic  variety  it  is  well  to  associate 
it  with  the  salts  of  lithia,  with  which 
we  have  had  most  excellent  results.  Von 
Eenterghem  and  Laura  (Dosimetric  Med. 
Review,  Oct.,  '97). 

Sodium  benzoate  has  a  positive  influ- 
ence in  preventing  alkaline  fermentation 
in  urine.  Of  a  number  of  samples  of 
urine  exposed  to  the  air  of  the  laboratory 
for  several  days,  none  became  alkaline. 
The  effect  of  benzoic  acid  does  not  di- 
rectly increase  the  normal  acid  of  the 
urine,  but  the  ammoniacal  fermentation 
is  prevented  and  the  normal  acidity 
asserts  itself.  The  beneficial  effects  ob- 
tained in  many  cases  of  cystitis,  where 
there  is  no  ammoniacal  fermentation  and 
no  residual  urine,  would  indicate  that 
this  substance  has  an  antiseptic  or 
germicidal  action.  This  influence,  how- 
ever, is  not  exerted  on  all  forms  of  bac- 
teria. The  diuretic  action  of  the  sub- 
stance is  inconstant.  W.  W.  Ashhurst 
(Phila.  Med.  Jour.,  Feb.  24,  1900). 

It  has  been  employed,  more  especially 
in  Germany  and  Scandinavia,  in  the 
management  of  certain  infectious  dis- 
eases, notably  mumps,  whooping-cough, 
measles,  scarlatina,  and  diphtheria,  and 
even  claimed,  when  the  administration 
is  begun  prior  to  the  period  of  incuba- 
tion, to  be  a  prophylactic  to  all.  But 
the  evidence  adduced  is  of  a  somewhat 
flimsy  character  and  requires  better  con- 
firmation. Lutzerich  and  Klein  used  it 
in  conjunction  with  calcium  sulphide  in 
diphtheria,  with  apparently  most  favor- 
able  results;    but  those  who  have  had 


much  experience  in  treating  this  mal- 
ady realize  how  unsafe  it  is  to  draw  de- 
ductions of  a  positive  character  from 
results  accruing  to  a  few  cases  in  one 
epidemic. 

Follicular  Tonsillitis.  —  In  affections 
of  the  throat  it  is  used  extensively.  It 
is  especially  valuable  in  follicular  ton- 
sillitis. 

In    100   cases   of   acute   follicular   ton- 
sillitis   4   to    15    grains    of    benzoate    of 
sodium    Avere    given    every    one    or    two 
hours.     The  duration  of  the  disease  was 
shortened  from  twelve  to  thirty-six  hours 
instead  of  lasting  two  to   five  days,  as 
is  usually  the  case.     In  some  instances 
the  white,  cheesy  points  disappeared  in 
eight    to   ten    hours.      L.    C.    Boislini6re 
(St.  Louis  Courier  of  Med.,  Feb.,  '88). 
Pharyngitis      and      Laryngitis.  —  In 
pharyngitis  this   medicament   favorably 
modifies  the  pain,   dysphagia,   and  in- 
flammation of  the  pharynx,  and  often 
cures  the  affection  in  two  or  three  days. 
In  such  cases  it  may  be  given  in  doses  of 
1  drachm  to  children,  and  3  drachms  to 
adults,  in  the  course  of  the  day. 

In  laryngitis  it  is  a  good  expectorant 

ivhen  administered  at  the  beginning  of 

the  disease.     Liegeois    (Med.   Press  and 

Circular,  Aug.  24,  '92). 

Gravel. — In  uric-acid  gravel  salicylate 

of  sodium,  as  does  benzoic  acid,  changes 

the  insoluble  urates   into   soluble  hip- 

pitrates,   and  thus   eliminates  the   acid 

from  the  urine. 

In  the  treatment  of  Bright's  disease, 
and  as  a  cholagogue,  this  drug  has  been 
found  of  much  service. 

BENZOIN. — Benzoin  is  a  gum  or  bal- 
samic resin,  the  concrete  juice  of  the 
Styrax  hmzoin:  a  large  tree,  native  of 
Peru:  It  appears  in  lumps,  agglutinated 
together,  yellowish  brown  in  color,  with 
a  milk-white  interior.  Benzoin  has  an 
agreeable  balsamic  odor,  and  a  slight 
aromatic  taste.     It  is  easily  pulverized. 


559 


the  process  being  apt  to  excite  sneezing. 
It  is  almost  wholly  soluble  in  five  parts 
of  moderately  warm  alcohol  and  in  solu- 
tions of  the  fixed  alkalies.  Its  chief 
constituents  are  resin  and  benzoic  acid. 

Dose. — Benzoinated  lard  (U.  S.  P.),  2 
per  cent.,  is  used  as  the  basis  for  benzoin 
ointments;  tincture  of  benzoin,  10  to  40 
minims;  compound  tincture  of  benzoin, 
15  minims  to  1  drachm. 

Physiological  Action.  —  Benzoin  pos- 
sesses antiseptic  properties,  and  the 
added  stimulating  effect  upon  mucous 
membranes  explains  its  value  in  the 
treatment  of  diseases  of  the  respiratory 
tract.  It  is  used  principally  in  phar- 
macy for  the  preparation  of  benzoic  acid. 

Therapeutics. — Benzoin  was  formerly 
employed  as  an  expectorant  in  pectoral 
affections,  but  has  fallen  into  disuse.  In 
the  treatment  of  diseases  of  the  upper 
respiratory  tract,  however,  it  has  main- 
tained a  well-deserved  reputation. 

Acute  Laryngitis.  —  In  this  disease 
rapid  results  are  attained  by  the  use  of 
inhalations  of  the  steam  of  a  pint  of  hot 
water,  containing  2  drachms  of  the  tinct- 
ure of  benzoin,  provided  the  patient  is 
given  at  the  same  time  5  grains  of  the 
benzoate  of  sodium  every  two  hours. 
The  hot  solution  of  benzoin  is  placed  in 
a  previously  warmed  vessel  and,  the 
latter  being  covered  with  a  towel  folded 
into  a  cone,  the  patient  inhales  through 
the  upper  opening  of  the  latter.  (Sajous.) 

Anal  Fissure. — The  tincture  of  ben- 
zoin is  being  strongly  recommended  in 
anal  fissure.  It  is  tised  to  paint  over 
abrasions  and  excoriations  in  order  to 
protect  the  surface. 

Chapped  Hands  and  Fissured  Nipples. 
— When  in  cold  weather  or  through  the 
use  of  hard  water,  the  hands  become 
chapped  and  fissured,  a  mixture  of  the 
compound  tincture  of  benzoin  and  glyc- 
erin, equal  parts,  is  of  great  service.    The 


same    preparation    is    advantageous    in 
fissured  nipples. 

Abrasions,  Chilblains,  Wounds,  Bed- 
sores, and  Granulating  Surfaces. — Owing 
to  its  antiseptic  virtues,  its  stimulating 
properties,  and  the  fact  that  it  protects 
the  parts  over  which  it  is  painted  with 
a  thin  film,  the  compound  tincture, 
painted  over  any  of  the  above  local  dis- 
orders, is  productive'  of  much  good. 

Eczema,  Pityriasis,  Urticaria,  and 
Frost-lite.  ■ —  The  tincture  of  benzoin,  2 
drachms;  glycerin,  2  drachms;  and  rose- 
water,  4  ounces,  used  as  a  lotion  may  be 
applied  with  advantage  to  either  of  the 
above  skin  disorders.  In  frost-bite,  how- 
ever, the  compound  tincture,  applied 
locally,  is  more  effective. 

Tincture  of  benzoin  useful  in  scabies. 
In  two  cases  the  itching  ceased,  and  the 
eruptions  began  to  disappear  after  the 
iirst  application,  and  the  patients  were 
finally  cured.  Vladimir  de  Holstein 
(Jour,  des  Mai.  Cutan,  et  Syph.,  Apr., 
'97). 

Liquid  benzoin  for  benzoinating  lard 
may  be  made  by  macerating  for  twelve 
hours  benzoin,  20,  in  ether,  40;  it  is  fil- 
tered and  castor-oil,  15,  is  dissolved  in 
the  filtrate,  from  which  the  ether  is  care- 
fully distilled.  This  oily  product  con- 
tains the  benzoic  acid  and  the  volatile 
principles.  To  make  benzoinated  lard, 
white  wax,  20,  is  melted  by  steam  heat 
with  dehydrated  lard,  965,  to  eliminate 
water;  the  above  liquid,  15,  is  added  and 
the  mixture  stirred  until  cold.  In  warm 
weather  a  large  amount  of  wax  should 
be  used.  E.  M.  Shoemaker  (Amer.  Jour, 
of  Pharmacy,  No.  1,  p.  9,  '98). 

BENZONAPHTHOL.      See   Naph- 

THALIN". 

BERIBERI.— Jap.,  Tcakhe.  It  has  been 
suggested  that  the  term  is  from  Iher- 
hheri,  a  Hindoo  word  meaning  a  sore  or 
swelling;  or  from  b'here,  a  sheep,  from 
the  fancied  resemblance  between  the  gait 
of  sufferers   from  this  disease   and  the 


560 


BEPaBERI.     SYMPTOMS. 


jerky  movements  of  sheep;  or  from  the 
Cingalese  word  beri-beri,  meaning  "great 
weakness."  The  latter  etymology  is 
almost  surely  the  correct  one. 

Definition.  —  A  23robably  specific  en- 
doepidemic  disease  characterized  by  mul- 
tiple peripheral  neuritis,  in  which  there 
is  numbness  and  stiffness  of  the  limbs, 
paralysis  of  the  extremities,  pain  and 
tenderness  on  pressure,  parssthesise,  and 
abolition  of  the  tendon  reflexes,  together 
with  frequent  anasarca,  cardiac  irregu- 
larity, and  gastro-intestinal  disorder, 
often  terminating  in  death. 

Symptoms.  —  Two  forms  of  beriberi 
are  met  with:  the  cedematous,  some- 
times termed  the  "wet"  form,  and  the 
paralytic,  or  "dry"  variety.  The  cedem- 
atous form  is  characterized  by  general 
anasarca,  with  the  appearance  of  great 
ana3mia.  It  usually  begins  with  fever, 
which  may  be  slight  and  intermittent. 
CEdema  of  the  extremities  then  sets  in, 
beginning  usually  over  the  dorsum  of 
the  foot  and  extending  upward.  As  the 
serous  effusion  into  the  subcutaneous 
cellular  tissue  takes  place,  puftiness  and 
numbness  follow.  A  peculiar  localized 
thickening  of  the  tissues,  or  "solid 
CEdema,"  is  sometimes  observed  over  the 
shin  and  in  the  thighs  and  chest.  With 
the  beginning  oedema,  cardiac  symptoms 
are  usually  observed,  this  fact  having 
caused  some  authors  to  attribute  the 
effusions  to  the  venous  stasis  resulting 
from  dilatation  of  the  right  ventricle. 
The  heart's  action  is  irregular,  rapid, 
palpitating,  and  frequent,  the  systole 
being  somewhat  increased  in  force  and 
louder  at  the  apex.  Loud  blowing  mur- 
murs, resembling  the  bruit  de  diable  of 
exophthalmic  goitre,  with  violent  pulsa- 
tion of  the  blood-vessels  in  the  neck  are 
present,  as  a  rule. 

In  a  great  number  of  cases  of  beriberi 
the  first  heart-sound  is  observed  to  be  so 


prolonged  as  to  be  considered  by  some 
authors  as  a  sanguineous  murmur.  Be- 
sides this  systolic  murmur  there  is  often 
violent  palpitation,  due  to  myocarditis, 
which  may  cause  death,  as  does  paralysis 
of  the  heart,  from  alterations  of  pneumo- 
gastric,  recurrent,  and  vasomotor  nerves, 
found  in  the  disease.  Albert  Ashmead 
(Inter.  Med.  Jour.,  '93). 

Study  of  the  modification  of  electrical 
reactions,  showing  relationship  between 
the  acceleration  of  the  pulse  and  the 
diminution  of  galvanic  excitability, 
though  not  in  all  cases.  Glogner  (Vir- 
choAv's  Archiv,  B.  132,  p.  50). 

The  respiration  is  embarrassed,  and 
prsecordial  pains  are  frequent. 

As  regards  the  digestive  system,  the 
tongue  is  usually  pale  and  flabby.  The 
appetite,  normal  at  first,  gradually  be- 
comes impaired;  disorders  of  digestion 
are  frequent  and  are  occasionally  accom- 
panied by  hsematemesis.  Constipation 
is  almost  the  rule.  The  urine  is  usually 
high-colored  and  scanty,  and  contains  no 
albumin,  unless  a  concomitant  affection 
be  present. 

The  pale,  blanched,  and  ansemic-look- 
ing  cutaneous  surface  does  not  indicate 
true   anemia,   since  examination   of  the 
blood   shows   percentage   of  haemoglobin 
slightly,   if   at   all,   lower   than   normal. 
E.  D.  Bondurant  (N.  Y.  Med.  Jour.,  Nov. 
20,  '97). 
In  the  so-called  "dry"  form  the  nerv- 
ous symptoms,  which  are  also  present  in 
the  cedematous  cases,  are  most  promi- 
nent.   Pain,  of  a  stinging,  burning,  and 
most  distressing  character,  is  frequent. 
Ansesthesia  to  touch  and  parsesthesia,  the 
latter    being    represented    by    pricking, 
formication,  and  tingling  (the  piri-piri 
of  the  Japanese),  are  prominent  symp- 
toms, paresis  of  the  extremities  accom- 
panying.    Cramps  are  sometimes   com- 
plained of.     The  knee-jerk  is  absent  in 
almost  every  case,  while  paralysis  of  the 
diaphragm  is  not  infrequent,  this  com- 
plication giving  rise  to  dyspnoea. 


BERI13ERI.     SYMPTOMS. 


561 


Paralysis  of  the  diaphragm  is  not  un- 
common  in    severe   cases.      Coughing   is 
thus  rendered  very   difficult,  and   dysp- 
noea is  not  uncommon;    ansEsthesia  and 
paresthesia  are   frequent,  beginning,   as 
a   rulCj    in   the   region    of   the    peroneal 
nerve.    Miura  (Virchow's  Archiv,  B.  123, 
H.  2J. 
The  motor  symptoms  are  usually  well 
marked,  and  the  gait  of  the  patient  is 
characterized  by  wobbly,  inco-ordinate, 
and  jerky  movements,  due  to  dropping 
and  inversion  of  the  foot.     In  advanced 
cases  the  power  of  locomotion  may  be 
entirely   lost.      In    cases   in   which   the 


Special  attention  lias  been  given  in 
the  Richmond  Asylum  to  the  condition 
of  the  joints.  The  relaxation  of  the 
ankle-  and  knee-  joints  is  extreme  in 
some  cases,  and  is  present  probably  in 
all.  In  many  tliis  condition  permits  the 
legs  and  feet  to  be  placed  in  postures  re- 
sembling those  occurring  in  subluxations 
of  the  knee  or  ankle.  This  condition 
gives  rise  to  a  cliaracteristic  wobbling  at 
the  knee  in  walking,  which  the  Japanese 
designate,  according  to  Professor  Ander- 


C'ases  of  beriberi,  late  stage,  showing  atrophy  of  muscles  of  legs  and 
foot-drop.     (Bonduvant.) 


morbid  changes  have  an  extensive  dis- 
tribution, the  patient  may  be  unable  to 
move.  The  upper  extremities  are  always 
involved  in  severe  cases. 

Muscular  atrophy  may  be  a  more  or 
less  prominent  late  feature  of  the  case, 
that  of  the  inferior  extremities  being  the 
most  pronoimced.  The  joints  are  greatly 
relaxed,  and  foot-drop  and  wrist-drop 
are  typically  shown  in  the  annexed  cuts. 
In  severe  cases  there  may  be  contracture. 

1- 


son,  by  the  term  gakii-gakii.     Editorial 
(Brit.  Med.  Jour.,  Aug.  14,  '97). 

Electrical  examination  shows  the  re- 
action of  degeneration,  even  in  acute 
cases. 

In  the  acute  form,  the  symptoms  out- 
lined follow  in  quick  succession,  and 
death  is  exceedingly  frequent.  This  is 
frequently  mentioned  as  the  "pernicious" 
form  of  beriberi. 

Disease   divided   into  three  forms:     1. 
36 


562 


BERIBERI.     SYMPTOMS. 


Acute,  with  pyrexia,  anaemia,  anasarca, 
serous  effusions,  paralj'sis,  and  dyspucea. 
2.  Subacute,  with  pain,  atrophic  paral- 
ysis, anaesthesia,  loss  of  knee-jerk,  mental 
debility,  and  oedema.  3.  Chronic,  with 
prostration,  anaemia,  cedema,  and  cardiac 
dilatation.  Thomas  (Edinburgh  Med. 
Jour.,  Jan.,  '90). 

Two  characteristics  not  yet  noticed: 
patients  are  subject  to  attacks  of  per- 
spiration, ordinarily  limited  to  the  head, 
but  sometimes  general.  In  addition,  two 
exceedingly    sensitive    points    are   to    be 


Case  of  beriberi,  early  stage,  showing  paralysis 
and  foot-drop.     (Bondurant.) 

found  on  the  feet :  one  toward  the  middle 
of  the  dorsal  face  of  the  first  intermeta- 
tarsal  space,  corresponding  to  the  bifur- 
cation of  the  internal  branch  of  the 
anterior  tibial  neiTC;  the  other  at  the 
cuboid  protuberance,  corresponding  to 
the  external  saphenous  nerve.  Previous 
to  any  treatment  the  patient  should  be 
withdrawn  fi'om  the  endemic  surround- 
ings. C.  E.  Corlette  (Brit.  Med.  Jour., 
Sept.  28,  '94). 

Case  of  suddenly  developing  beriberi: 
(Edematous  paralysis  with  blindness.    The 


patient  sulTered  from  optic  neuritis  with 
central  scotoma  and  consequent  blind- 
ness. The  urine  exhibited  a  sensible 
diminution  of  urea  and  an  almost  par- 
allel decrease  of  other  constituents. 
There  was  a  decrease  of  the  red  blood- 
corpuscles  and  an  increase  of  the  leuco- 
cytes. In  several  muscles  a  partial  reac- 
tion of  degeneration  was  obtained,  not- 
withstanding the  return  of  voluntary 
motion.    Mosse  (Med.  Bull.,  Jan.,  '95). 

Series  of  seventy-one  eases  which,  dur- 
ing 1895-'96,  occurred  among  the  patients 
in  the  State  Insane  Hospital,  at  Tusca- 
loosa, Ala.  A  striking  feature  of  the 
disease  was  its  variability  in  mode  of 
onset.  Some  eases  began  suddenly  with 
fever  and  gastro-intestinal  irritation,  as 
is  commonly  seen  in  the  acute  infections, 
the  local  neuritie  symptoms  appearing 
either  simultaneously  or  after  a  few 
days.  In  other  instances  the  onset  was 
insidious,  the  initial  vague  aches,  pains, 
and  discomfort  gradually  crystallizing 
into  the  clinical  picture  of  neuritis  with- 
out fever  or  general  systemic  disorder, 
it  being  in  many  of  these  cases  impos- 
sible to  date  the  commencement  of  the 
attack.  In  still  other  cases  the  initial 
symptom  was  suddenly  occurring  dysp- 
noea, with  tachycardia  and  violent  pul- 
sation of  the  vessels  of  the  neck;  cedema 
of  feet  and  ankles  was,  in  others,  the 
first  indication. 

The  temperature  was,  in  about  half  of 
the  cases,  elevated  in  the  beginning,  but 
usually  subsided  to  normal  within  a 
week  or  less. 

The  clinical  manifestations  of  inflam- 
mation of  the  peripheral  nerves  varied 
in  intensity,  distribution,  and  character, 
but  always  consisted  in  weakness,  per- 
version, or  abolition  of  function  of  the 
affected  nerve-trunk.  In  all  cases  the 
disease  began  in  the  nerves  of  the  legs. 

The  sensory  symptoms  were  frequently 
those  to  first  attract  attention :  pain  and 
tenderness  in  the  area  of  distribution  of 
the  affected  nerve,  at  first  aching  and 
not  very  severe,  but  becoming  progress- 
ively more  intense,  and  at  its  height  very 
distressing. 

The  motor  symptoms,  appearing  with 
or  shortly  after  the  sensory  disorders, 
were:     stiffness  in  muscles  supplied   by 


BERIBERI.     DIAGNOSIS. 


563 


affected  nerves,  progressing  through 
simple  weakness  and  disinclination  to 
exertion  to  some  degree  of  paralysis,  this, 
in  severe  eases,  becoming  complete. 

Vasomotor  and  trophic  disorders,  other 
than  the  oedema  in  affected  parts,  which 
is  referred  to  below,  were  not  frequent. 

Almost  without  exception  the  portions 
of  the  body  supplied  by  affected  nerves 
grew  oedematous. 

The  chief  and  earliest  symptom  of 
heart-implication  is  rapidity  of  action, 
with  weakness.  This  begins  about  or 
shortly  after  the  time  the  nerves  of  the 
body  and  arms  become  attacked. 

The  rapidity  of  heart-action  in  these 
eases  Avill  average  about  130,  but  may 
show  a  higher  rate.  In  one  extreme  ease 
the  pulse  for  three  weeks  ranged  between 
180  and  210,  the  patient  suffering  sur- 
prisingly little  dyspnoea.  E.  D.  Bondu- 
rant  (N.  Y.  Med.  Jour.,  Nov.  20,  '97). 

Diagnosis. — Beriberi  prevails  en- 
demically  in  tropical  and  subtropical 
conntries,  especially  in  Brazil,  the  West 
Indies,  India,  and  Ceylon.  That  it  also 
occurs  occasionally  in  temperate  climates 
has  recently  been  shown  by  the  out- 
breaks at  the  Eichmond  Asylum,  in 
Dublin,  and  the  Insane  Hospital  at  Tus- 
caloosa, Alabama.  Its  peculiar  charac- 
ters readily  cause  it  to  be  recognized,  and 
the  diseases  with  which  it  can  be  eon- 
founded  are  few. 

Malignant  Dropsy. — This  affection  is 
less  infectious  and  attacks  exclusively 
the  insane.  Paralysis  is  never  observed. 
The  digestive  tract  is  unaffected.  The 
progress  is  slow,  and  in  an  epidemic  very 
few  persons  are  affected,  differing  in 
these  respects  from  beriberi.  (Melen- 
dez.) 

Ceylon  Ancemia. — This  affection,  due 
to  the  presence  in  the  intestines  of  the 
Anchylostoma  duodenale,  is  also  charac- 
terized by  weakness  and  numbness;  but 
there  are  no  true  motor  symptoms,  and 
intestinal  haemorrhage  is  frequent  (Kyn- 
sey).     The  anchylostomum  is  sometimes 


found  in  beriberi,  and  the  two  affections 
are  considered  as  similar  by  some  authors. 

Anchylostomiasis  is  common  in  coun- 
tries (such  as  Italy)  where  beriberi  is 
not  found.  Anchylostomum  filaria  san- 
(jiiinis  or  TrichocepluiJus  dispar  may  be 
present  in  beriberi;  but  they  are  co- 
incidents, and  not  a  cause.  Anchylos- 
tomiasis has  symptoms  not  at  all  like 
beriberi.  Giles  (Indian  Med.  Rec,  July, 
'90). 

AneJiylostomum  duodenale,  a  human 
parasite  found  in  tropical  countries,  and 
especially  in  Ceylon,  gives  rise  to  grave 
aneemia,  often  ending  in  death.  This 
affection,  the  kala-azar,  or  beriberi,  of 
Ceylon,  bears  no  resemblance  to  the  true 
beriberi,  except  a  cachexia,  often  accom- 
panied by  muscular  weakness  and 
dropsy.  Giles  (Indian  Med.  Record, 
July,  '90). 

Two  cases  of  beriberi  associated  with 
Distoma  crassum,  Anchylostoma  duode- 
nale, and  other  parasites.  James  Walker 
(Brit.  Med.  Jour.,  Dec.  5,  '91). 

Beriberi  a  peripheral  neuritis,  inde- 
pendent of  the  presence  of  anchylostoma; 
the  affection  produced  by  the  latter  is 
absolutely  distinct  from  beriberi.  Leslie 
(Brit.  Med.  Jour.,  Feb.  27,  '92). 

Beriberi  and  the  kala-azar  of  Assam 
are  identical;  the  latter  an  anchylosto- 
miasis caused  by  the  Dochmius  duode- 
nalis.  Giles  (N.  Y.  Med.  Jour.,  Mar.  26, 
'92). 

In  beriberi  (endemic  neuritis)  we  must 
look  for  the  characteristic  cardiac  and 
nerve  symptoms  and  the  reaction  of  de- 
generation. 

In  anchylostomiasis  (parasitic  anaemia) 
we  must  search  for  the  worm  after  the 
exhibition  of  thymol,  or  by  microscopical 
examination  of  a  portion  of  the  excreta 
for  the  ova  of  the  parasite. 

In  kala-azar  (epidemic  malarial  fever), 
which  is  confined  to  Assam,  we  have  the 
history  of  the  sure  and  slow  spread  and 
evidence  of  its  infectiveness. 

The  co-existence  of  malarial  cachexia 
with  either  beriberi  or  anchylostomiasis, 
as  very  frequently  happens  in  tropical 
countries,  renders  an  exact  diagnosis 
sometimes  difficult,  and  it  is  this  fact 
which,  in  countries  where  malaria  is  very 


564 


BERIBERI.     ETIOLOGY. 


common,  has  stood  so  much  in  the  way 
of  clear  ideas  on  the  above  diseases.  W. 
J.  Buchanan  (Dublin  Jour.  Med.  Sci- 
ences, Dec,  '97). 

An  epidemic  of  peripheral  neuritis  is 
probably  one  of  beriberi.  When,  in  the 
beginning,  the  symptoms  are  indistinct, 
the  subsequent  rapid  development  of 
oedema  and  paresis,  in  the  absence  of  any 
other  cause — e.g.,  nephritis — points  to 
that  disease. 

Malarial  neuritis  of  a  character  simu- 
lating beriberi  is  exceedingly  rare.  It  is 
generally  confined  to  one  nerve;  besides, 
paresis,  muscular  atrophy,  and  cardiac 
disturbances  are  absent.  If  the  Plasmo- 
dium of  Laveran  is  found  and  the  disease 
responds  to  quinine,  the  diagnosis  is 
cleared  up;    both  diseases  may  co-exist. 

In  alcoholic  neuritis  we  have,  besides 
a  history  of  drinking,  gastric  catarrh  and 
mental  disturbances,  ffidema  is  infre- 
quent in  uncomplicated  cases.  It  is  pos- 
sible, ho^^■ever,  for  malaria,  beriberi,  and 
alcoholic  neuritis  to  be  present  in  the 
same  patient. 

In  lathyrism,  due  to  the  poison  of  the 
Latfiyrus  sativus,  there  is  no  oedema,  an- 
aesthesia, or  cardiac  disturbance. 

In  trichinosis  the  pain  is  principally  in 
the  muscles  of  the  trunk,  head,  and  neck. 
Violent  gastro-intestinal  paroxysms  pre- 
cede the  muscular  pain.  Cardiac  trouble 
and  paresis  are  absent.  0.  D.  Norton 
(Indian  Lancet,  June   16,  '98). 

Polymyositis,  polyneuritis,  and  Lan- 
dry's paralysis  have  so  many  symptoms 
in  common  with  beriberi  that  they  are 
probably  to  be  considered  as  sporadic 
cases  of  that  disease.  Ebbell  (Norsk 
Mag.  f.  Laegevidensk.,  p.  629,  '99).  F. 
Levison,  Corr.  Ed. 

Etiology. — Until  recently  a  great 
diversity  of  opinion  has  existed  regard- 
ing the  cause  of  this  affection.  The 
researches  of  Pekelharing  and  Winkler 
have  increased  the  probability  that  beri- 
beri is  caused  by  the  presence,  in  food 
and  infected  habitations  or  ships,  of  a 
specific  micro-organism. 

In  the  blood  of  beriberi  patients 
bacilli  and  micrococci  are  to  be  found. 


Pure  cultures  of  these  micrococci  give 
a  nerve-degeneration  of  like  nature  to 
that  found  in  beriberi  when  injected  into 
rabbits  and  dogs.  The  inhalation  of 
air  impregnated  Avith  such  culture  can 
originate  a  nerve-degeneration  in  rabbits. 
Beriberi  must,  in  all  probability,  be  re- 
garded as  a  contagious  disease  induced 
by  the  action  of  a  micro-organism.  The 
infecting  micrococcus  can  also  exist  apart 
from  contact  with  the  human  being. 

Direct  transmission  from  one  person 
to  another  rarely  occurs;  infection 
through  wearing-apparel  is  more  com- 
mon. The  infecting  material  finds  its 
way  into  the  body  principally  through 
the  respiratory  organs.  The  spread  of 
the  malady  can  be  interrupted  by  dis- 
infection, or,  in  a  person  attacked,  by 
removal;  when  the  symptoms  are  once 
well  developed  nothing  but  Nature  can 
effect  a  cure.  Pekelharing  and  Winkler 
(An  Investigation  into  the  Nature  and 
Origin  of  Beriberi,  and  the  Means  to  be 
Adopted  for  Counteracting  the  Disease, 
'88). 

Examination  of  20  specimens  of  hair 
from  beriberi  patients.  Nineteen  speci- 
mens were  obtained  from  Penang,  and 
\  from  India.  Out  of  these  20  specimens, 
6  contained  arsenic.  The  specimen? 
which  contained  arsenic  were  obtained 
from  recent  eases,  while  nearly  all  the 
negative  specimens  oame  from  older 
cases.  This  result  augments  the  evi- 
dence in  favor  of  beriberi  being  due  to 
arsenic,  since  it  suggests  that  the  ar- 
senic was  present  only  at  a  certain  stage 
of  the  disease.  R.  Ross  (Brit.  Med 
Jour.,  Feb.  8,  1902). 

While  the  discovery  of  the  specific 
micro-organism  is  yet  to  be  verified,  clin- 
ical evidence  has  shown  that  overcrowd- 
ing, as  in  the  case  in  ships,  associated 
with  defective  and  noxions  ventilation 
and  moisture  and  oftentimes  insufficient 
or  improper  diet,  tend  to  cause  the 
development  of  the  disease.  By  thus  de- 
bilitating the  system  and  rendering  the 
latter  amenable  to  the  pathogenic  effects 
of  the  germ,  such  untoward  conditions 
of  life  miffht  act  as  an  indirect  factor. 


BKRIBERI.     ETIOLOGY. 


565 


Living  in  a  confined  atmosphere  and 
in  districts  favorable  to  eryptogamic 
vegetation  has  considerable  influence  in 
the  production  of  beriberi.  Agapito  de 
Veiga  (Int.  Med.  Jour.,  Aug.,  '93). 

Three  cases  in  colored  men  who  had 
•worked  in  phosphate-beds.  Probably 
caused  by  microbe  of  telluric  origin,  dis- 
tinct from  that  of  malaria.  Dercuni 
(Joui-.  of  Nerv.  and  Mental  Dis.,  Feb., 
'94). 

Whole  crew  affected  in  ship  loaded 
with  fermenting  Manila  hemp;  also  in 
another  vessel  loaded  with  fermenting 
cocoa-nut  fibre.  Ashmead  (N.  Y.  Med. 
Eec,  Nov.  24,  '94;  Univ.  Med.  Mag., 
Aug.,  '95;    N.  Y.  Med.  Eec,  Oct.  5,  '95). 

Regarding  the  epidemic  at  the  Rich- 
mond Asylum,  Dublin:  "Not  only  is  the 
whole  institution  overcrowded  far  be- 
yond its  normal  accommodation,  but 
even  the  new  wooden  building  for  males 
is  not  fit  to  contain  more  than  half  the 
number  at  present  occupying  it.  Its  two 
dormitories  are  at  present  occupied  by 
100  patients,  although  not  suited  to  give 
sanitary  accommodation  to  more  than 
50.  The  women's  permanent  hospital 
contains  as  many  as  6?  patients,  who 
have  an  average  of  451.968  cubic  feet  of 
space  each."  This  space  ought  properly 
to  sufiSce  for  the  accommodation  of  25 
patients.  Sir  Thornley  Stoker  (Boston 
Med.  and  Surg.  Jour.,  Aug.  12,  '97). 

In  addition  to  bad  ventilation  and 
overcrowding,  it  is  also  recognized  that 
insufficient  diet  encourages  the  develop- 
ment of  the  disease.  But  it  should  be 
borne  in  mind  that  these  conditions 
foster,  but  do  not  generate,  beriberi. 
The  morbid  entity  which  causes  it  must 
be  imported  into  the  locality  in  which 
the  vicious  environment  prevails:  an  en- 
vironment which  is  eminently  favorable 
to  the  development  of  many  other  epi- 
demic diseases.  Editorial  (Lancet,  Aug. 
14,  '97). 

In  the  seventy-one  cases  which  oc- 
curred in  the  Insane  Hospital  at  Tusca- 
loosa, Ala.,  the  first  case  developed  in 
February,  1895.  The  disease  was  not 
again  seen  until  November,  1895,  when 
almost  simultaneously  seven  cases  de- 
veloped among  the  white  female  patients. 


During  the  succeeding  six  weeks  five 
cases  made  their  appearance,  all  of  simi- 
lar type.  After  a  period  of  immunity 
the  disease  reappeared  in  the  late  sum- 
mer of  1890,  when,  following  a  season  of 
unusual  dryness  and  distressing  heat, 
fifty-eight  patients  were  attacked.  State- 
ment giving  the  average  population  of 
the  hospital  during  the  period  covered 
by  the  outbreak: — 


Approxim.ite  uumber  of  patients 
in  hospital 

Number  of  eases  of  beriberi 

Fatal  cases  of  beriberi_ 

Number  of  epileptics  in  liospital.. 

Number  of  cases  of  beriberi  in 
epileptics 


Peculiar  distribution  among  the  sev- 
eral classes  of  insane  patients:  every 
one  of  the  seventy-one  patients  attacked 
was  the  subject  of  a  psychical  degenera- 
tive form  of  mental  disorder.  E.  D. 
Bondurant  (N.  Y".  Med.  Jour.,  Nov.  20, 
97). 

The  nature  of  the  food,  as  shown  in 
the  results  obtained  by  a  change  of  diet 
in  the  Japanese  navy,  has  an  important 
bearing  upon  the  development  of  the 
disease.  The  influence  is  but  an  indi- 
rect one,  however,  operating  also  by  pre- 
paring the  field  for  microbic  infection, 
the  latter  only  taking  place  when  the 
person  enters  an  infected  abode. 

Rapid  spread  in  Brazil;  rice  the  cause. 
Azevedo  (Deutsche  med.  Zeit.,  Aug.  25, 
'90). 

The  aboriginal  Aino,  a  great  fish-eater, 
is  very  rarely  attacked.  Grimm  (Deut- 
sche med.  Woch.,  Oct.  23,  '90). 

Rice-eating  has  weight  in  the  etiology. 
Takaki  (Sei-I-Kwai  Med.  Jour.,  Oct.  25, 
•90). 

The  disease  due  to  abnormal  fermenta- 
tion in  the  intestines  under  certain  cir- 
cumstances, the  ferment  being,  perhaps, 
a  micro-organism.  Oni  (Sei-I-Kwai  Med. 
Jour.,  Jan.  23,  '92). 


566 


BERIBERI.    ETIOLOGY. 


Success  in  controlling  a  considerable 
number  of  eases  of  beriberi  in  the  Japan- 
ese navy,  by  adopting  a  food-regiraen  in 
which  rice  is^  for  the  greater  part,  re- 
placed by  beef,  pork,  eggs,  etc.  Of  3063 
eases  per  million  in  1883,  in  1889  there 
were  only  388.  Takaki  (Brit,  Med.  Jour., 
Sept.  24,  '92). 

Three  cases  in  which  the  cause  of  the 
disease  seemed  to  be  the  use  of  old  pre- 
serves, in  which,  however,  the  pathog- 
enic agent  was  not  to  be  found.  Kirch- 
berg  (Gaz.  Med.  de  Nantes,  Dec.  12,  '93). 

Ascribed  to  eating  diseased  tunny-fish. 
It  was  common  in  the  Japanese  navy 
until  fish  was  abolished  from  the  diet; 
vegetable-eating  prisoners  are  also  ex- 
empt. Miura  (Virehow's  Avchiv,  vol. 
exix). 

Cases  in  which  mieroseopioal  and  bac- 
teriological examination  showed  blood  to 
be  free  from  any  parasites.  Disease  prob- 
ably due  to  toxaemia  caused  by  pto- 
maines derived  from  special  kinds  of 
food.  Judson  Daland  (N.  Y.  Med.  Jour., 
Mar.  9,  '95). 

A  toxeemia  of  alimentary  origin  (rice, 
fish)  ;  for  cure,  European  rations  indi- 
cated. Grail,  Porc6,  and  Vincent  (Revue 
Inter,  de  Med.  et  de  Chlr.,  July  10,  '95) . 

In  stamping  out  the  disease  in  the 
Japanese  navy,  however,  besides  the  im- 
proved dietary,  very  important  hygienic 
improvements  were  introduced  at  the 
same  time.  D.  C.  Rees  (Brit.  Med.  Jour., 
Sept.  18,  '97). 

The  seventy-one  cases  at  Tuscaloosa 
seemingly  due  to  use  of  Avater  contami- 
nated by  decaying  vegetable  matter.  E. 
D.  Bondurant  (N.  Y.  Med.  Jour.,  Nov. 
20,  '97). 

Attention  drawn  to  spread  of  this  dis- 
ease to  suckling  infants  through  the 
milk  of  nursing  mothers  suffering  from 
it.  Of  52  cases  in  such  infants,  42  re- 
covered and  5  died,  the  result  in  the  re- 
maining 5  cases  being  unknown.  Cows' 
milk  or  condensed  milk  was  mostly  sub- 
stituted for  human  milk.  Improvement 
occurred  almost  at  once.  It  is  personally 
maintained  that  the  disease  is  I'eally  due 
to  an  intoxication  brought  about  by  the 
milk,  and  that  the  only  sure  cure  is  to 
withhold  the  milk,  and  this  before  the 


disease  is  too  advanced.  Hirota  (Cen- 
tralb.  f.  innere  Med.,  Apr.  23,  '98). 
Cold  and  damp  have  been  regarded  as 
etiological  factors,  the  disease  occurring 
most  frequently  on  board  of  ships  during 
the  winter,  probably  owing  to  the  fact 
that  those  exposed  are  more  likely  to 
remain  huddled  together  in  close  quar- 
ters than  during  other  seasons.  The  re- 
cent epidemics  at  the  Eiehmond  Asylum 


Negro  paranoiac,  of  a  degenerate  type  which 
seemed  especially  susceptible  to  the  poison 
of  beriberi.     {Bondurant.) 

and  at  Tuscaloosa,  Ala.,  however,  oc- 
curred during  the  warm  months,  and 
the  latter  during  a  period  of  excessive 
dryness. 

Two  epidemics  of  beriberi  occurring  on 
board  ship,  which  appear  to  prove  very 
conclusively  that  this  disease  is  propa- 
gated through  the  drinking-water.  In 
both  cases  the  men  were  healthy  as  long 
as  they  still  had  a  supply  of  European 
water,  although   staying  for  some   time 


BERIBERI.     ETIOLOGY. 


567 


at  places  where  the  disease  is  endemic. 
But,  the  water  having  run  short,  they 
had,  in  the  one  case,  to  lay  in  fresh  water 
at  Batavia  and,  in  the  other,  at  Mauri- 
tius, in  both  of  which  places  the  disease 
occurs  endemically.  About  four  weeks 
after  commencing  to  drink  this  water 
the  disease  broke  out  among  the  crew. 
It  would  thus,  also,  appear  that  the  in- 
cubation period  of  beriberi  is  about  one 
month.  Roll  (Norsk  Mag.  f. 
videnskaben,  Nov.,  '95;    May,  '96). 


European  or  mulatto  contracted  beriberi, 
there  were  45  cases  among  the  aborigi- 
nals. Length  of  residence  in  the  jail  and 
want  of  occupation,  together  with  over- 
crowding, defective  ventilation,  inade- 
quate provisions  for  cleanliness,  and  the 
removal  of  filth  were  the  chief  deter- 
mining causes.  The  affection  generally 
commenced  toward  the  third  month  of 
incarceration.  Compulsory  exercise  was 
invariably  followed  by  an  amelioration 
of  symptoms,  but  if  the  patient  remained 


Imbecile  and  paranoiac  imbecile,  illustratiBg  types  of  degenerates  most  liable 
to  beriberi.     (Bondurant.) 


Case  of  beriberi  on  top  of  Fujiyama, 
Japan,  in  the  month  of  December,  as- 
cribed to  insufficient  alimentation  and 
constipation.  Miura  (Sei-I-Kwai  Med. 
Jour.,  June,  '96) . 

At  the  Dakar  prison  in  Senegal,  west- 
ern Africa,  the  total  number  of  prisoners 
under  observation  in  1895  was  647,  of 
whom  52  were  Europeans,  the  remainder 
being  natives.  The  two  classes  lived 
under  identical  conditions;     whereas  no 


in  prison  a  relapse  ending  fatally  was 
sooner  or  later  certain  to  supervene.  Of 
tAvelve  prisoners  suffering  from  beriberi 
for  whom  pardon  was  asked  in  order 
that  their  lives  might  be  saved,  five 
were  dead  before  the  official  intimation 
reached  Dakar  three  months  later.  The 
seven  survivors  were  at  once  set  at  lib- 
erty, and  eventually  all  of  them  recov- 
ered. Unhygienic  conditions  an  impor- 
tant factor,  but  the  chief  cause  of  the 


568 


BERIBERI.     PATHOLOGY. 


disease  is  the  lack  of  suitable  employ- 
ment. Lasnet  (Archives  de  Med.  Navale 
et  Coloniale,  Feb.,  "97). 

Marked  predominance  of  the  number 
of  outbreaks  that  occur  in  the  wet  and 
cold  months  of  the  year,  when,  presum- 
ably, the  native  sailors  will  remain 
huddled  up  in  their  stuffy  forecastle. 
Out  of  the  157  cases  recorded,  96  oc- 
curred between  October  1st  and  Febru- 
ary 28tli;  the  remaining  61  occurred 
between  March  1st  and  September  30th. 
It  has  been  shown  that  in  a  certain 
group  of  vessels,  all  drawing  their  food- 
supply  presumably  from  the  same  source, 
in  only  one-half  of  their  number  did 
beriberi  occur;  and,  further,  that  one 
epidemic  undoubtedly  renders  a  ship 
liable  to  future  outbreaks. 

The  history  of  the  outbreaks  at  the 
Richmond  Asylum  tends  to  prove  that 
beriberi  is  a  "place"  disease  and  not  a 
"food"  disease.  It  is  highly  improbable 
that  the  same  food-supply  was  used  in 
this  asylum  during  the  epidemics  of  1894, 
1896,  and  1897.  With  all  these  facts 
before  us,  we  are  justified  in  adhering 
to  the  belief  that  an  outbreak  of  beriberi 
depends  on  "place"  infection  plus  favor- 
able predisposing  conditions.  D.  C.  Eees 
(Brit.  Med.  Jour.,  Sept.  18,  '97). 

Forty-five  deaths  from  this  disease 
among  506  men  of  the  Australian  pearl- 
ing fleet,  in  voyages  lasting  altogether  53 
months.  They  sustain  the  view  (1)  that 
beriberi  is  confined  to  a  very  great  ex- 
tent to  rice-eating  races,  and  with  proper 
care  will  not  develop  in  less  than  sixteen 
months;  (2)  that  the  substitution  of  a 
mixed  diet  of  wheat-flour,  beans,  pota- 
toes, etc.,  to  the  exclusion  of  rice,  miti- 
gates, even  if  it  does  not  prevent,  the 
disease.  Lime-juice  is  not  very  useful, 
but  beer  is  very  beneficial.  T.  H.  Haynes 
(Jour,  of  Tropical  Med.,  Mar.  15,  1900). 

Epidemic  of  beriberi  in  a  foundling- 
house.  There  had  been  one  or  two  cases 
in  a  blind-asylum  near  by,  the  inmates 
of  which  came  in  contact  with  the  chil- 
dren in  the  foundling-house.  Sixty-nine 
cases  occurred,  and  only  27  healthy  chil- 
dren were  left  in  the  house.  Two  of  the 
patients  with  beriberi  died,  the  remain- 
der were  improving.  The  children  at- 
tacked were  all  between  4  and  7  years 


of    age.      Their    hygienic    surroundings 
were   good,  and  the  diet  was  excellent. 
All  those  attacked  slept  on  the  ground 
floor.     F.  Clarke   (Brit.  Med.  Jour.,  May 
12,  1900). 
Other  factors  in  the  etiology  of  the 
disease  are  fatigue,  exhausting  diseases, 
exposure  to  marked  alternations  of  tem- 
perature, all  conditions  tending  to  sap 
the  vital  energies  and  reduce  the  nutri- 
tion of  the  nerve-centres,  and  to  prepare 
the  system  for  the  attacks  of  the  infec- 
tious principle. 

Pathology. — Pekelharing  and  Winkler 
have  obtained  from  the  blood  of  beri- 
beri patients  a  micrococcus  which,  inocu- 
lated in  animals,  produced  polyneuritis. 
Ogata  and  Lacerda  ascribe  the  disease  to 
a  bacillus  resembling  that  of  anthrax. 
Musso  and  Morclli  have  isolated  four 
micro-organisms:  a  staphylococcus  pyog- 
enes albus;  a  micrococcits  in  chains;  a 
small  micrococcus;  and,  last,  a  small 
organism  which,  inoculated  in  dogs  and 
guinea-pigs,  produced  a  imiversal  degen- 
erative neuritis. 

It  cannot  be  said,  however,  that  the 
specific  organism  of  beriberi  has  been 
foimd.  All  that  can  now  be  admitted  is 
that  it  infects  asylums,  barracks,  prisons, 
the  holds  of  ships,  and  other  abodes 
where  the  hygienic  surroundings  are  de- 
ficient. 

The  researches  of  Baelz  and  Scheube, 
in  Japan,  and  those  of  Pekelharing  and 
Winkler,  in  Java,  have  done  much  to 
elucidate  the  pathology  of  beriberi.  The 
former  ascribed  to  a  multiple  neuritis 
the  symptoms  of  the  disease,  while  the 
latter  observers  advanced  and  upheld 
with  powerful  evidence  the  view  that  the 
staphylococcus  was  the  primary  factor 
in  its  production.  The  disease  is  mainly 
one  of  the  peripheral  nervous  system, 
which  shows,  in  various  regions  remote 
from  the  cord  and  brain,  more  or  less 
pronounced  degeneration. 


BERIBERI.    PATHOLOGY. 


569 


Results  of  fourteen  autopsies.  In  the 
brain  and  spinal  cord  nothing  abnormal 
found  except  the  presence  of  vacuoles  in 
the  ganglion-cells  of  the  spinal  cord:  a 
fact  of  little  significance.  In  almost  all 
of  the  cases  there  were  cardiac  hyper- 
trophy and  dilatation.  The  muscular 
tissue  of  the  heart  usually  appeared 
normal,  fatty  degeneration  was  rare,  but 
in  two  cases  there  were  many  granular 
cells  in  the  interstitial  tissue  of  the 
heart-muscle.  There  were  no  character- 
istic changes  in  the  lungs.  In  a  number 
of  cases  the  kidneys  showed  alterations 
in  structure,  usually  in  the  form  of 
glomerulonephritis.  The  liver  was  usu- 
ally of  the  nutmeg  variety,  and  the 
spleen  normal.  The  muscles  very  com- 
monly showed  the  "waxy  degeneration" 
described  by  Zenker  and  also  a  multi- 
plication of  the  nuclei  of  the  sarcolemma 
and  an  increase  in  the  connective  tissue. 
Miura   (Virchow's  Archiv,  Feb.,  '88). 

North  Brazil  as  the  father-land  of  the 
disease,  from  which  it  has  been  spread 
by  commercial  intercourse  with  other 
nations.  Two  forms:  the  oedema tous  and 
the  paralytic.  Four  forms  of  bacteria. 
W.  Leopold  (Berliner  klin.  Woch.,  No.  4, 
'92). 

Four  micro-organisms  were  isolated,  as 
follows:  (1)  staphylococcus  pyogenes 
albus;  (2)  micrococci  in  chains;  (3)  a 
small  streptococcus,  colorless,  of  un- 
known character  and  difficult  cultiva- 
tion; and  (4)  a  micrococcus  which,  by 
inoculation  in  guinea-pigs  and  dogs, 
causes  a  degenerative  neuritis,  and  is  de- 
scribed as  the  micrococcus  of  beriberi. 
Musso  and  Morelli  (Berliner  klin.  Woch., 
Jan.  2.5,  '93). 

Beriberi  due  to  a  bacillus  cultivated 
from  rice;  the  same  found  in  the  blood 
of  rats  that  had  died  after  eating  the 
rice.  De  Lacerda  (Bentley:  "Beriberi"; 
Seheube:     "Die  Beriberi-Krankheit"). 

Organism  sought  in  the  blood  of 
patients  while  alive.  Numerous  micro- 
organisms— cocci  and  rods — found. 

Inoculative  experience  leading  to  the 
conclusion  that  a  white  micrococcus  cul- 
tivated from  the  blood  is  the  cause  of 
beriberi.  These  white  cocci  impregnate 
the  air  of  the  infected  houses,  ships,  and 
districts,  get  into  the  human  circulation 


through  the  air-passages,  and  when  tliey 
are  absorbed  in  suflScient  amount — some 
weeks'  exposure  to  the  infection  being 
necessary — produce  in  the  blood  toxins 
in  such  quantity  and  of  such  a  nature 
as  to  bring  about  a  parenchymatous 
degeneration  of  the  peripheral  nerves. 
Pekelharing  and  Winkler  ("Beriberi," 
Edinburgh,  '93). 

Pekelharing  and  Winkler  did  not  pro- 
duce beriberi  in  the  animals  injected; 
the  cocci  found  by  them  are  not  the 
cause  and  not  even  one  of  the  causes  of 
the  disease.  Beriberi  cannot  probably  be 
produced  by  several  organisms,  as  sug- 
gested. The  cause  of  beriberi  has  not 
yet  been  ascertained.  Seheube  ("Die 
Beriberi-Krankheit,"   '94) . 

Bacillus,  found  in  the  spinal  cord  of  a 
patient  who  had  died  from  beriberi,  re- 
sembling the  anthrax  bacillus.  Cultures 
injected  in  mice  and  dogs  caused  the  de- 
velopment of  the  symptoms  of  beriberi. 
This  bacillus  being  found  in  the  intes- 
tines of  patients,  conclusion  reached  that 
it  was  the  toxins  of  these  bacilli  being 
absorbed  into  the  circulation  that  caused 
the  paralytic  symptoms.  Ogata  (Bent- 
ley:  "Beriberi";  Seheube:  "Die  Beri- 
beri-Krankheit," '95). 

A  micrococcus  cultivated  from  the 
blood  and  ascitic  fluid  of  two  cases  of 
beriberi,  which,  wien  Injected  into  rab- 
bits, produced  symptoms  of  beriberi. 
Musso  and  Morelli  (Sternberg's  "Bac- 
teriology," '96). 

Cocci  cultivated  from  the  blood  of 
beriberi  patients;  by  inoculating  rabbits 
with  the  growth  the  symptoms  of  that 
disease  produced.  De  Lacerda  (Stern- 
berg's "Bacteriology,"  p.  473,  '96) . 

In  spite  of  the  arduous  researches  of 
Pekelharing.  Winkler,  and  others  the 
organism  which  is  the  cause  of  beriberi 
has  not  been  satisfactorily  or  certainly 
determined.  Spencer  (Lancet,  Jan.  2, 
'97). 

Four  varieties  of  organisms  cultivated 
from  the  blood  of  beriberi  patients,  as 
follows:  (1)  micrococcus  albus:  a  mi- 
crococcus which  was  immobile,  aerobic 
and  which  liquefied  gelatin;  (2)  micro- 
coccus tetragonum  flavus:  cocci  arranged 
in  tetrad  forms;  (3)  micrococcus  flavus: 
also  aerobic  and  liquefying  gelatin;    and 


570 


BERIBERI.     PATHOLOGY. 


(4)  bacillus  flavus:  short  rods  in  pairs 
and  chains,  in  active  motion,  aerobic, 
and  with  spore-formation.  On  injecting 
animals  with  these  growths,  three  of 
them — the  first,  third,  and  fourth — each 
produced  paralysis.  No  result  was  ob- 
tained with  micrococcus  tetragonum 
flavus.  Van  Eecke  (Scheube:  "Die  Beri- 
beri-Krankheit,"  '97).  The  above  nine 
abstracts  quoted  from  an  article  by  W. 
K.  Hunter   (Lancet,  July  31,  '97). 

Study  of  two  cases,  including  inocula- 
tion experiments,  tending  strongly  to 
show  that  the  staphylococcus  of  Pekel- 
haring  and  Winkler  is  the  specific  micro- 
organism of  beriberi. 

Although  Fiebig  has  argued  that  it 
has  the  same  characters  as  staphylococ- 
cus pyogenes  albus,  and  that  it  is  the 
same  organism,  the  pathogenic  charac- 
ters of  the  two  are  very  different.  The 
staphylococcus  pyogenes  albus  injected 
into  the  abdominal  cavity  of  a  rabbit 
would  produce  septic  results.  In  not  one 
of  six  rabbits  did  an  abscess  form  at  the 
seat  of  inoculation,  and  in  not  one  was 
any  inflammatory  condition  of  the  peri- 
toneum to  be  made  out.  W.  K.  Hunter 
(Lancet,  July  31,  '97). 

Two  cases  of  beriberi,  in  both  of  which 
specimens  of  freshly-drawn  blood  showed 
micro-organisms  in  rapid  motion  in  the 
spaces  between  the  groups  of  corpuscles. 
Of  30  tubes  of  culture-media  (agar-agar 
and  bouillon-tubes)  that  were  inoculated 
with  tlie  blood  3  growths  were  obtained 
from  one  case  and  1  from  the  other. 
These  presented  all  characters  of  staphy- 
lococcus of  beriberi.  Three  of  the  cases 
were  pure  and  one  a  mixed  infection. 
Pathogenic  properties  of  the  staphylo- 
cocci found  were  determined  by  injecting 
rabbits. 

There  were  no  macroscopical  post- 
mortem lesions.  The  nerves,  however, 
showed  microscopically  unmistakable 
parenchymatous  degeneration.  W.  K. 
Hunter  (Lancet,  June  25,  '98). 

Experiments  showing  that  the  blood  of 
a  patient  suffering  from  beriberi  con- 
tained a  substance  that  caused  a  fall  of 
arterial  pressure  when  injected  in  the 
veins  of  animals.  The  same  result  is 
caused  by  the  choline  found  in  the  cere- 
bro-spinal    fluid    from    cases    of   general 


paralysis  of  the  insane.  The  presence  of 
choline  in  the  former  case  could  not  be 
proved  chemically.  Mott  and  Hallibur- 
ton (Brit.  Med.  Jour.,  July  29,  '99). 

When  the  disease  has  advanced,  the 
various  organs  are  infiltrated  with  serous 
fluid,  and  the  tissues,  especially  the 
muscular,  undergo  degeneration.  The 
heart  is  enlarged,  and  the  kidneys  also 
present  marked  evidence  of  degenera- 
tion. 

Histological  examination;  conclusion 
that  the  disease  is  an  infectious  lesion 
rapidly  destroying  the  epithelium  of  the 
kidneys,  liver,  and  muscles,  particularly 
the  cardiac  fibres,  by  granulo-fatty  de- 
generation; it  causes  the  production  of 
masses  of  new  cells  in  the  connective 
tissue  of  the  liver,  spleen,  kidneys,  spinal 
marrow,  and  brain  and  certain  nerves, 
the  vagus  in  particular.  Nepveu  (Mar- 
seille-medical, June  15,  '94). 

Series  of  seventy-one  cases  which,  dur- 
ing 1895-96,  occurred  among  the  patients 
in  the  State  Insane  Hospital  at  Tusca- 
loosa, Ala.  Of  the  21  fatal  cases,  1  pa- 
tient died  of  pulmonary  tuberculosis,  1 
of  pneumonia,  2  in  the  status  epilep- 
tictis,  14  directly  from  heart-failure,  and 
the  remaining  3  from  a  combination  of 
causes.  The  complications  hastened  or 
insured  a  fatal  termination  in  6  or  7 
cases.  E.  D.  Bondurant  (N.  Y.  Med. 
Jour.,   Nov.   20,   '97). 

In  general,  it  may  be  said  that,  the 
nearer  the  equator,  the  more  numerous 
the  hydropic  forms  and  the  greater  the 
mortality.  The  mortality  is  always  high 
when  the  patients  continue  to  live  under 
the  same  conditions  and  in  the  same 
place  as  that  in  which  the  disease  was 
contracted.  The  lethal  complications  are 
respiratory  and  cardiac  failure  and  bron- 
chitis. 0.  D.  Norton  (Indian  Lancet, 
June  16,  '98). 

Prognosis. — The  mortality  of  beriberi 
varies  considerably  in  different  epidemics, 
and  may  range  from  8  to  44  per  cent. 
On  shipboard  the  number  of  deaths  may 
surpass  that  proportion. 


571 


Beriberi  may  cause  death  in  three 
ways,  these  being,  in  the  order  of  fre- 
quency, by  failure  of  the  heart  from  pe- 
ripheral paralysis  of  its  special  nerves; 
by  sufEocation  from  congestion  and 
cedema  of  the  lungs;  by  effusion  into 
the  pericardium.     (Max  Simon.) 

A  peculiarity  of  this  disease  is  its 
tendency  to  relapse,  and  the  fact  that 
with  each  relapse  the  prognosis  becomes 
much  more  unfavorable. 

Treatment.  —  The  first  step  should 
naturally  be  to  remove  the  patient  from 
the  unhygienic  surroundings  in  which 
he  may  find  himself,  and  especially  from 
germ-infected  abode.  Out-of-door  life 
and  suitable  diet  are  the  primary  ele- 
ments of  cure. 

As  to  remedial  measures,  the  symp- 
toms should  be  treated  as  they  occur, 
there  being  no  specific  remedy  at  our  dis- 
posal. The  oedema  should  be  met  with 
acetate  of  potassium,  squill,  and  digitalis. 
Cathartics  may  be  administered  to  an- 
tagonize the  constipation,  opium  to  ar- 
rest the  pain,  and  camphor,  digitalis, 
and  strophanthus  be  given  when  cardiac 
symptoms  appear.  Diaphoretics  and  hot 
vapor-baths  are  useful  in  the  oedematous 
form,  unless  they  debilitate  the  patient. 
When  there  is  marked  dyspnoea  ether, 
hypodermically,  is  of  great  service. 
Methylene-blue,  3  grains  two  or  three 
times  a  day,  was  found  very  valuable  by 
Thur,  and  salicylate  of  soda  by  Berry, 
of  Boston.  When  the  case  is  beginning 
to  improve,  electricity.  Judiciously  em- 
ployed, may  prove  of  great  benefit  to 
stiniulate  the  vasomotor  system  and 
increase  the  nutrition  of  the  muscles. 
Massage  also  is  valuable. 

Strychnine,  in  gradually  increasing 
doses  xmtil  slight  toxic  phenomena  are 
produced,  is  capable  of  bringing  about 
a  cure  even  when  the  paralysis  is  com- 
plete.   The  treatment  is  begun  with  Vgo 


grain,  and  the  same  quantity  is  added 
every  third  day  until  ^/^  grain  is  taken. 
If  the  disease  should  return,  the  initial 
dose  of  Veo  grain  should  again  begin  the 
course  of  treatment.    (Domingos  Freire.) 

The  berry  of  the  Phaseolus  radiatus, 
a  common  plant,  has  proved  effectual 
in  the  treatment  of  beriberi.  It  was 
thoroughly  tested  on  the  two  hundred 
and  fifty  to  three  hundred  inmates  of 
the  asylum,  and  displayed  a  marked 
prophylactic  action  when  an  average  of 
150  grammes  of  the  peas  were  eaten 
regularly  every  day.  No  injurious 
effects  of  any  kind  were  noted  even 
after  prolonged  use.  It  also  proved  a 
good  remedy  against  the  infection  it- 
self, but  had  no  influence  on  the  se- 
quelae. The  oedema  rapidly  subsided 
under  its  influence,  and  likewise  the 
paresis  in  the  acute  cases,  which  is 
liable  to  persist  for  months.  Its  in- 
fluence was  particularly  beneficial  in  the 
severer  forms  of  the  disease.  The  asy- 
lum has  long  been  affected  with  beri- 
beri, but  not  a  single  case  has  occurred 
in  the  pavilion  in  which  the  inmates 
take  regularly  150  grammes  of  the  peas 
in  their  daily  ration.  The  natives  make 
great  use  of  these  peas  both  in  their 
own  food  and  for  poultry.  Burg  (Janus, 
Oct.,  1902). 

E.    D.    BOXDUEANT, 

Mobile. 

BETAKAPHTHOL.      See    jSTaphtha- 

LIN. 

BICAEBONATE      OE     POTASSIUM. 

See  PoTASsiuii. 

BICARBONATE    OF    SODIUM.      See 

Sodium. 

BICHLORIDE    OE   MERCURY.     See 

Mehctjet. 

BISMUTH.— Bismuthum  is  a  whitish- 
gray,  hard,  though  brittle,  metal,  with 
melting-point  at  286.3°  C.  It  is  soluble 
in  nitrohydrochloric,  nitric,  and  hot  sul- 
phur acids. 


572 


BISMUTH.     PHYSIOLOGICAL  ACTION. 


It  is  very  commonly  contaminated 
with  lead,  iron,  and  copper,  together 
with  traces  of  arsenic,  antimony,  and 
tellnrinm. 

In  the  metallic  form  bismuth  is  not 
used  in  medicine,  but  its  salts,  particu- 
larly if  free  from  contamination,  are  of 
great  value. 

The  garlicky  odor  sometimes  produced 
in  the  breath  of  patients  taking  the  salts 
of  bismuth  is  due  to  the  presence  of  the 
metal  tellurium.  This  fact  was  first 
noticed  by  Sir  James  Simpson,  and  was 
established  further  in  1875,  when  spec- 
imens of  bismuth  containing  tellurium 
as  an  impurity  invariably  produced  in 
the  breath  the  peculiar  odor  referred  to. 

The  salts  of  bismuth  are  numerous, 
but  only  the  most  efficient  will  be  men- 
tioned, together  with  dosage. 

Dose.  • —  The  subcarbonate  is  a  white, 
tasteless  powder  soluble  in  dilute  nitric 
acid  with  effervescence.  Dose,  5  to  30 
grains. 

The  subnitrate  occurs  as  a  white  mi- 
croerystalline  powder  soluble  in  acids. 
Dose,  5  to  20  grains. 

Bismuth  citrate  is  a  white  amorphous 
powder,  odorless  and  tasteless,  and  sol- 
uble in  solutions  of  the  alkali  citrates. 
Dose,  1  to  5  grains. 

The  benzoate  is  a  white,  tasteless  pow- 
der soluble  in  mineral  acids.  It  contains 
27  per  cent,  of  benzoic  acid.  Dose,  5  to 
15  grains. 

Bismuth  betanaphtholate  occurs  as  a 
light-brown,  insoluble,  odorless  powder. 
Dose,  15  to  30  grains. 

The  salicylate  of  bismuth  is  a  white, 
bulky  microcrystalline  powder  soluble  in 
acids  and  alkalies.    Dose,  5  to  20  grains. 

The  subgallate  is  well  known  under 
the  name  of  dermatol  {q.  v.).  It  is 
without  odor,  non-irritant,  and  non- 
poisonous.    Dose,  5  to  20  grains. 

Physiological  Action. — When  applied 


to  excoriated  or  ulcerated  surfaces  the 
salts  of  bismuth,  for  the  most  part,  exert 
an  astringent  and  sedative  action.  The 
claims  that  some  of  the  salts  of  bismuth 
possess  antiseptic  properties  —  the  or- 
ganic compounds — have  been  substanti- 
ated by  experimentation  and  practical 
observation:  salicylate,  benzoate,  and 
betanaphtholate. 

Contrary  to  the  observations  of  Morax 
and  von  Pfungen,  bismuth  in  large  doses 
possesses  the  property  of  decreasing  no- 
tably the  amount  of  sulphuric  acid  in 
combination  among  those  subjects  whose 
food  consisted  chiefly  of  albuminoid  sub- 
stances; indican  is  decreased  and  at 
times  it  disappears.  The  action  of  bis- 
muth is  poorly  understood;  these  facta 
show  that  intestinal  putrefactions  dimin- 
ish decidedly,  despite  that  checking  of 
intestinal  peristalsis  which  bismuth  ef- 
fects. Devoto  (Semaine  Mgd.,  No.  54, 
'94). 

Bismuth  naphtholate    (bismuth   oxide, 

80  per  cent.,   and  betanaphthol,   20  per 

cent.)   decidedly  antiseptic.     The  drug  is 

partly  decomposed  in  the  stomach,  but 

the   process   is   completed   in    the    small 

intestine.     R.   W.   Wilcox    (Med.   News, 

July  31,  '97). 

The   action   of   the   salts   of  bismuth 

when    taken    internally    in    therapeutic 

doses  is  much  the  same  as  when  applied 

locally. 

The    salicylate    of    bismuth    causes    a 
slight  increase  in  the  elimination  of  sul- 
phuric  ether  by  the   urine.     This  elim- 
ination is  somewhat  diminished  two  or 
three   days   after   the  administration   of 
the    drug.      Ecvighi     (Monat.    f.    prakt. 
Wasserheil.,  p.  372,  '93). 
The  subnitrate  is  a  powerful  bacteri- 
cide.    It  is  to  this  action  that  it  owes 
those  virtues  which  have  been  for  a  long 
time  universally  appreciated  in  gastro- 
intestinal diseases  that  are  the  result  of 
morbid  fermentation,  and  in  urethritis. 
It  also  owes  its  efficaciousness  to  the  in- 
dependent action  of  its  oxide  and  its  acid. 
The  oxide  has  the  property  of  saturating 


BISMUTH.     POISONING. 


573 


the  acid  siipersecretions  of  the  stomach; 
the  acid  has  the  same  qualities  and  un- 
dergoes slow  chemical  changes  in  the 
intestine.     From  the  time  it  comes  in 
contact  with  these  digestive  regions  the 
subnitrate  meets  with  hydrosulphurous 
emanations,  which,  although  transform- 
ing it  into  the  black  sulphide,  set  a  cor- 
responding proportion  of  nitric  acid  free. 
Because  of  its  own  acidity,  the  nitric 
acid  acts  directly  on  the  intestinal  mu- 
cous membrane  as  an  astringent;   but  to 
this  topical  action  its  special  antiseptic 
virtues  may  be  added,  for,  according  to 
Duclaux,  the  presence  of  a  trace  of  nitric 
acid  in  an  organic  solution  arrests  the 
evolution  of  a  great  number  of  microbes 
and  hastens  their  destruction.     Mean- 
while  its   bactericidal   action    does   not 
cease  here;  from  the  time  that  it  comes 
in  contact  in  its  intestinal  course  with 
fresh  hydrosulphurous  vapors  it  is  re- 
duced   and    transformed    into    nitrous 
vapors,  the  special  antiseptic  action  of 
which,  in  regard  to  the  bacteria  which 
secrete  putrid  gases,  has  been  shown  by 
Girard  and  Pabst. 

Bismuth  subnitrate,  in  doses  of  1  V2  to 
2  draclims,  loweis  the  ratio  of  sulphuric- 
aeid  compounds  in  patients  living  prin- 
cipally on  albuminoid  diet.  At  the  same 
time  indican  diminishes  or  entirely  dis- 
appears from  the  urine.  This  shows  that 
putrid  fermentation  going  on  in  the  in- 
testine diminishes  in  spite  of  the  fact 
that,  under  the  influence  of  bismuth,  in- 
testinal peristalsis  has  been  suppressed. 
Devoto  (Eev.  Inter,  de  Ther.  et  Phar., 
Nov.  15,  '95). 

The  use  of  the  organic  in  place  of  the 
inorganic  bismuth  should  be  insisted  on. 
The  compounds  of  bismuth  with  beta- 
naphthol,  phenol,  tribromphenol,  and 
tetraiodophenolphthalein  are  remedies 
which  produce  practical  intestinal  anti- 
sepsis. They  are  indicated  in  all  gastro- 
intestinal fermentations  and  catarrhs 
until  the  symptoms  are  relieved,  the  dose 
to  be  determined  by  the  severity  of  the 
symptoms.     They  are  non-toxic  and  do 


not   give   rise    to    untoward   symptoms. 
Wilcox   (Med.  News,  July  31,  '97). 

Bismuth  is  poisonous  when  introduced 
under  the  skin.  It  should  not,  there- 
fore, be  employed  subcutaneously  under 
any  circumstance. 

Poisoning.  —  Poisoning  may  occur 
either  from  local  application  of  bismuth 
preparations,  from  internal  administra- 
tion, or  from  subcutaneous  injection. 

A  number  of  cases  of  poisoning  re- 
corded, produced  by  the  absoi-ption  of 
insoluble  preparations  of  bismuth  when 
used  as  surgical  applications,  in  which 
there  was  acute  stomatitis,  a  blackened, 
ulcerated  mucous  membrane,  followed  by 
intestinal  catarrh  with  pain  and  diar- 
rhoea, and  in  severe  cases  by  a  true 
nephritis.  Kocher  (Volkmann's  Samm. 
klin.  Vort.,  No.  224,  '87) ;  Petersen 
(Deutsche  med.  Woeh.,  June  30,  '87). 

Case  of  poisoning  by  bismuth.  A 
young  woman  had  a  large  burn  on  the 
back,  which  was  powdered  with  subni- 
trate of  bismuth.  A  dark  line  appeared 
on  the  lips,  with  headache,  nausea, 
vomiting,  fever,  and  quick  pulse,  and 
the  urine  contained  a  small  quantity  of 
albumin.  Neither  lead  nor  arsenic  was 
found  by  analysis  in  the  bismuth  em- 
ployed. N.  L.  Wilson  (N.  Y.  Med.  Jour., 
Jan.  20,  '94). 

In  the  early  studies  of  bismuth  the 
effects  of  acute  poisoning  by  the  sub- 
nitrate of  bismuth  were  alone  observed. 
More  recently,  however,  injecting  into 
dogs  repeated  doses  of  the  compound  at 
intervals  of  several  days  or  hours  has 
given  results  closely  allied  to  those  ob- 
served in  the  human  being  by  Kocher 
and  Petersen,  save  that  death  followed 
in  the  train  of  these  signs,  which  were, 
by  reason  of  the  large-size  dose,  very 
severe.  Ulcerations  replaced  the  aph- 
thous patches,  the  liver  was  found  con- 
gested, and  the  coats  of  the  large  intes- 
tine blackened.  These  changes  come  on 
in  strong,  healthy  dogs  weighing  from 
fourteen   and   one-half  to    fifteen   kilo- 


574 


BISMUTH.     POISONING.    TREATMENT.    THERAPEUTICS. 


grammes     (twenty-nine     to     thirty-five 
pounds).     (Dalche  and  Villejean.) 

The  distinction  which  is  to  be  drawn 
between  a  stomatitis  resulting  from  the 
prolonged  use  of  bismuth  and  that 
which  is  commonly  seen  after  continued 
doses  of  mercury  consists  in  a  lesser  de- 
gree of  ptyalism.  "While  the  color  of  the 
spot  usually  becomes  black  if  caused  by 
bismuth,  it  seldom  becomes  so  dark  in 
hue  under  the  influence  of  mercury. 
The  changes  in  the  vascular  system, 
which  are  caused  by  bismuth  in  chronic 
poisoning,  consist  in  the  dilatation  of  the 
blood-vessels,  with  consequent  relaxation 
and  congestion  of  the  part. 

Case  of  a  patient  who  had  been  at- 
tacked three  times  by  a  scarlatiniform 
erythema,  followed  by  desquamation  in 
patches,  in  consequence  of  having  taken 
30  grains  of  bismuth  subnitrate  that  had 
been  prescribed  after  an  attack  of  diar- 
rhoea. Amfidee  Dubreuihl  (Bull.  Gen.  de 
Th6r.,  p.  229,  '97). 

Twins,  3  weeks  old,  given  Squibb's 
subnitrate  of  bismuth  in  the  dose  of 
7  V;  grains  every  two  hours,  increased 
to  15  grains  each  every  two  hours. 
Soon  the  bismuth  passed  from  the  bowels 
uncolored.  The  breath  took  a  strong, 
garlicky  odor,  so  much  so  that  the 
mother  remarked  about  the  peculiar 
odor.  The  infants  then  slowly  changed 
to  a  dark  color,  as  if  asphyxiated.  In- 
fants sleepy.  Drug  almost  ■\\'holly  with- 
drawn; the  cyanosis  disappeared  from 
both  children  as  rapidly  as  it  had  come. 
A.  S.  Maxson  (Annals  of  Gynec.  and 
Ped.,  July,  '97)'- 

Two  cases  in  which,  as  the  result  of 
extensive  burns  upon  the  arm,  bismuth 
dressings  were   applied,   causing  bluish 
discoloration,    swelling,    and   superficial 
ulcers   of  the  gums.     These  were  only 
controlled  when   the   bismuth   still   ad- 
hering to  the  granulations  was  scraped 
off.     Muehlig   (Miinohener  med.  Woch., 
Apr.  9,  1901). 
Treatment  of  Poisoning.  —  The  stom- 
ach should  be  evacuated  and  the  freshly 
prepared    sesquioxide    of   iron   adminis- 


tered as  the  antidote  to  arsenic  which  is 
commonly  combined  with  the  native  bis- 
muth. Demulcents  should  be  freely  ex- 
hibited, and  stimulants  as  the  case  may 
require.  Following  the  administration 
of  the  soluble  salts  of  bismuth  accumula- 
tion in  the  liver  may  occur;  but  this  is 
not  likely  to  follow  the  use  of  the  in- 
soluble preparations. 
Therapeutics. 

Locally. — Many  of  the  bismuth  salts 
are  useful  when  applied  locally.  The 
subnitrate  of  bismuth  is  a  neglected 
remedy  for  external  use.  It  has  been 
found  very  useful  in  acute  and  chronic 
moist  eczemas,  as  well  as  in  intertrigo 
and  excoriations  in  the  region  of  the 
anus  and  genitalia  in  children.  In  fis- 
sured nipples,  herpes  zoster,  ulcers,  and 
in  afllections  of  the  mucous  membranes 
it  has  also  proved  serviceable. 

Of  the  many  bismuth  preparations, 
biit  one  may  be  substituted  for  iodoform, 
namely:  bismuth  salicylate. 

In   the   first  period   of   the   chancroid 
and  in  tubercular  ulcerations  of  the  skin, 
if   the   salicylate   of   bismuth    is   dusted 
once  a  day  on  the  diseased  area,  after  a 
few  applications  the  granulations  become 
florid   and   the   lesions   show    a   marked 
tendency  toward  cicatrization.    R.  Brin- 
disi  (Ther.  Gaz.,  Mar.  15,  '95). 
Dyspepsia.  —  Many  of  the  bismuth 
preparations  have  decided  value  in  the 
treatment  of  gastro-intestinal  disorders. 
Bismuth   tribromophenolate   useful   in 
cases     of    gastric    fermentation.      Toxic 
symptoms  never  observed,  although  ad- 
ministered   in    doses    ranging    from    90 
to   120   grains   daily.     Harmlessness   at- 
tributed  to   a   slow    decomposition    and 
the  setting  free  of  phenol.    R.  W.  Wilcox 
(Med.  News,  July  31,  '97). 

Bismuth  salicylate  is  inferior  to  bis- 
muth subnitrate.  The  former  drug  pre- 
cipitates the  albuminoid  ferments,  and, 
therefore,  it  has  an  unfavorable  action 
in  gastric  affections.  Bismuth  salicylate 
acts  by  virtue  of  the  salicylic  acid  that 
it  contains,  and,  on   that  account,  dys- 


BISMUTH.     THEKAPEUTICS. 


575 


pepsia,    renal    affections,    old    age,    ath- 
eroma, pregnancy,  and  nervous  diseases, 
in  which  salicylic  acid  is  contra-indicated, 
also   contra-indicate   this   salt.     Thabius 
(Gaz.  Hebdom.  de  Med.  et  de  Chir.,  Dec. 
31,  '99). 
Dj'spepsia  attended  with  hyperacidity, 
irritable  stomach,  and  gastric  carcinoma 
are  often  happily  influenced  by  the  ad- 
ministration of  bismuth. 

For  such  the  following  may  be  used: — ■ 
I^   Subnitrate  of  bismuth, 

Carbonate  of  magnesia,  of  each,  5 

grains. 
Morphine  sulphate,  V12  grain. 
M.    For  one  powder. 
Gasteic   TJlcee.  —  This   disorder   is 
benefited  by  10-  or  15-grain  doses  of 
the  subnitrate  or  benzoate  three  or  four 
times  daily.     The  addition  of  a  small 
quantity  of  morphine  markedly  increases 
the  analgesic  action. 

Chloroform- water  with  bismuth 
(water,  150;  bismuth,  3;  chloroform,  1) 
very  valuable  in  chronic  gastric  ulcer. 
Its  beneficial  effects  are  due  to  its  anti- 
septic, astringent,  and  haemostatic  prop- 
erties. It  also  exerts  a  stimulant  effect 
locally,  healing  the  ulcer.  Stepp  (Ther. 
Monats.,  Nov.,  '93). 

Fleiner's  method  of  treating  irritative 
diseases  of  the  stomach  with  large  doses 
of  bismuth  very  successful,  especially  in 
lessening  pain.  Massive  doses  are  of  use 
especially  in  gastric  ulcer.  Matthes 
(Centralb.  f.  klin.  Med.,  Jan.  6,  '94). 

In  cases  of  gastric  ulcer  excellent  re- 
sults obtained  by  giving  large  dosea  of 
bismuth  by  the  mouth  in  cases  where 
the  ordinary  doses  had  not  proved  suc- 
cessful. Doses  of  30  to  40  or  even  50 
grains  of  bismuth  subnitrate  were  given 
three  times  a  day  suspended  in  water. 
Under  these  pain  was  rapidly  relieved, 
vomiting  ceased,  digestion  improved,  al- 
lowing light  nitrogenous  food,  such  as 
fish  or  fowl,  to  be  given,  and  the  ulcer 
quickly  healed.  In  acid  dyspepsia  it 
rapidly  relieved  the  symptoms.  In  neu- 
rasthenic conditions,  with  symptoms  re- 
sembling those  of  gastric  ulcer,  it  also 
was  of  great  service.     Two  cases  of  gas- 


trie  ulcer,  which  were  not  relieved  by 
large  doses  of  bismuth  given  by  the 
mouth,  were  cured  by  injecting  the  bis- 
muth into  the  stomach  after  lavage. 
Dresehfeld  (Brit.  Med.  Jour.,  Mar.  12, 
'98). 

Diarrhoea.  —  Acute  or  chronic  diar- 
rhoeas are  often  relieved  by  bismuth. 

A  dose  of  castor-oil  in  advance  of  bis- 
muth subnitrate  is  of  value  in  removing 
any  possible  cause  of  irritation.  (Ringer.) 
In  severe  diarrhoea  in  children  it  is 
best  never  to  commence  with  a  dose  of 
less  than  5  or  8  grains,  and  it  is  possible 
to  dispense  entirely  with  opium  in  many 
instances.  Its  beneficial  action  is  un- 
doubtedly due  as  much  to  the  antiseptic 
power  of  the  salicylic  acid  as  to  the 
astringent  property  of  the  bismuth. 
(Hale.) 

It  can  best  be  administered  to  chil- 
dren in  a  mixture  with  glycerin  and 
water,  to  be  shaken  before  taken.    The 
form  of  powder  should  be  avoided,  as 
liable  to  produce  irritation  of  the  gastro- 
intestinal mucous  membrane.     (Ehring.) 
Naphthol    is    the    remedy    most    fre- 
quently  employed  to  procure  intestinal 
antisepsis,  but  the  burning  taste  some- 
times  renders    its    use    impossible,    par- 
ticularly in  children,  and  it  is  custom- 
ary to  combine  it  with  a  bismuth  salt. 
Much  more  advantageous  to  use  instead 
naphtholate  of  bismuth,  or  betanaphthol- 
bismuth,  which  decomposes  in  the  intes- 
tine into  naphthol  and  bismuth.     Chau- 
mier    (Eev.   Gen.   de   Clin,   et  de   Th6r., 
Sept.  21,  '95). 

In  a  very  severe  case  of  intestinal 
putrefaction  bismuth  naphtholate  found 
to  give  great  relief,  limiting  the  tympan- 
ites, removing  the  offensive  odor,  and  im- 
proving nutrition.  R.  W.  Wilcox  (Med. 
News,  July  31,  '97). 

Typhoid  Fetee. — Bismuth  betanaph- 
tholate  is  a  very  efficient  agent  in  the 
diarrhoea  of  this  disease,  especially  in 
intestinal  hsemorrhage,  giving  the  drug 
freely  by  the  mouth  as  soon  as  the  first 


576 


BISMUTH. 


BLEPHARITIS. 


bloody  stool  is  observed.  From  2  Yj  to  3 
ounces  may  be  administered  in  twenty- 
four  hours,  in  doses  of  2  V2  drachms, 
either  in  lactic-acid  lemonade,  diluted 
milk,  or  cachets;  1  ounce  may  be  given 
to  a  child  of  12  years,  in  quince-syrup 
or  boiled  milk.     (Letulle.) 

Bismutli     subiodide     and     salol     seem 
to    diminish    tympanites,    control    diar- 
rhoea,   and    prevent    haemorrhage.      The 
two     drugs     administered     alternately. 
Twenty-six  cases  were  thus  successfully 
treated.     Farrar    (Med.   News,   Jan.   16, 
'92). 
Vomiting. — Many  cases  of  vomiting, 
even  that  of  pregnancy,  will  usually  yield 
to  the  administration  of  20-grain  doses 
of  one  or  other  of  the  bismuth  salts.    It 
is  not  always  tolerated  by  the  stomach, 
however,  that  of  infants  especially.    This 
drawback  may  be  oviated  by  combining 
it  with  an  aromatic  powder  or  magnesia. 

BLACK  TONGUE.  See  Tongue,  Dis- 
eases OF. 

BLACK-WATER  FEVER.  See  Ma- 
laria. 

BLADDER.  See  Cystitis.;  Urinary 
System,  Diseases  of;  Urinary  Sys- 
tem, Surgical  Diseases  of. 

BLADDER,  WOUNDS  OF.  See  Ab- 
dominal Injuries,  Bladder. 

BLEPHARITIS  AND  BLEPHARAD- 
ENITIS. 

Definition.  —  Blepharitis  can  best  be 
defined  as  an  inflammation  of  the  Mei- 
bomian, or  sebaceous,  glands  of  the  hair- 
follicles,  and,  secondarily,  of  the  follicles 
themselves.  It  may  occur  as  a  symptom 
of  some  form  of  reflex  irritation  from 
refraction  errors,  or  may  accompany 
conjunctival  irritations,  stricture  of  the 
tear-duct,  and  inflammations  of  all  sorts. 

Symptoms.  —  Slight  localized  swelling 
at  the  edge  of  the  lid  is  the  first  mani- 
festation of  the  disease.    This  gradually 


spreads  until  the  entire  edge  of  the  upper 
lid  is  involved.  Crusts  then  appear 
around  the  bases  of  the  cilia  of  the 
swollen  part  and,  the  secretions  being 
infectious,  gradual  extension  to  the  lower 
lid  follows.  Some  of  the  cilia  in  the 
inflamed  follicles  become  loosened,  and 
may  easily  be  withdrawn  without  causing 
pain,  or  they  may  fall  out  imbedded 
in  the  crusts.  Chronic  conjunctivitis, 
phlyctenular  conjunctivitis,  and  tra- 
choma frequently  occur  as  concomitants 
or  complications. 

Etiology.  —  Blepharitis  is  more  com- 
mon in  strumous  persons.  It  frequently 
presents  itself  as  a  result  of  excessive  use 
of  the  eyes  in  reading,  etc.  Apart  from 
the  parasitic  and  traumatic  varieties  of 
blepharitis,  it  is  usually  of  reflex  origin, 
due  to  uncorrected  refraction  errors. 
As  a  rule,  blepharitis  ciliaris  may  be  re- 
garded as  a  sort  of  optical  barometer  or 
as  an  expression  of  the  amount  of  func- 
tional strain;  this  is  made  manifest  by 
a  more  or  less  intense  variety  of  blepha- 
ritis or  blepharadenitis  (chronic  blepha- 
ritis), and  in  my  experience  usually  ac- 
companies errors  of  refraction  other  than 
myopia.  So-called  "styes" — hordeola — 
accompany  blepharitis,  and,  with  reten- 
tion-cysts and  tarsal  tumors,  are  the  re- 
sult of  blepharadenitis  or  chronic  bleph- 
aritis, with  stenosis  or  stricture  of  the 
excretory  ducts  and  abscesses  of  the 
Meibomian  glands  as  a  sequence.  The 
varieties  are: — 

1.  Blepharitis  ciliaris:  acute,  simple; 
caused  by  reflex  refraction  error. 

2.  Blepharitis  ciliaris:  marginal  and 
ulcerative,  acute  or  chronic,  conjunc- 
tival, trachomatous,  diphtheritic,  strict- 
ure of  lacrymal  duct,  etc. 

3.  Blepharitis  ciliaris:  eczematous, 
squamous,  exudative,  pedicular. 

4.  Blepharitis  ciliaris:  furunculous, 
infectious,  autoinfectious. 


BLEPHAKITIS.     PATHOLOGY.     PROGNOSIS.     TREATMENT. 


577 


5.  Blepharitis  eiliaris:  exanthematous, 
erysipelatous,    phlegmonous,    traumatic. 

6.  Blepharitis  eiliaris:  blepharadeni- 
tis,  chronic  Meibomian  and  follicular 
inflammation  and  obstruction. 

Pathology. — If  the  crusts  are  washed 
off  and  the  base  of  the  lashes  are  mag- 
nified and  carefully  examined,  it  will  be 
seen  that  the  mouths  of  the  follicles  no 
longer  closely  surround  the  cilia.  The 
latter  are  thus  loosened.  In  more  ad- 
vanced cases  the  follicles  are  destroyed 
by  the  inflammatory  process  and  the 
lashes  are  no  longer  reproduced,  the  seat 
of  their  former  implantation  becoming 
bare  cicatricial  tissue.  The  loss  of  the 
protection  afforded  the  eye  from  light 
and  the  mucous  surfaces  of  the  lid  by  the 
cilia  increases  the  sources  of  irritation 
and  inflammation;  involvement  of  the 
lacrymal  puneta  may  then  give  rise  to 
lacrymation  and  eversion  of  the  lid;  con- 
junctival and  corneal  inflammations  fol- 
low as  formidable  complications. 

Prognosis. — Chronic  congestion  of  the 
edge  of  the  lids,  with  slight  swelling,  is 
a  trivial  condition  which  is  promptly 
cured  if  judiciously  treated.  The  ulcer- 
ative form  is  less  easily  mastered,  and 
the  complications  that  are  likely  to  fol- 
low make  it  important  that  blepharitis 
Teceive  attention  in  its  early  stages. 

Treatment. — In  the  first  and  second 
varieties  the  crusts  must  be  carefully 
soaked  and  mopped  with  a  warm,  alka- 
line solution  in  the  hands  of  the  patient 
until  softened.  They  should  not  be 
iorcibly  removed.  Pledgets  of  absorbent 
cotton  should  be  used  to  sop  or  mop  the 
crusts  and  not  disturb  the  cilia,  which 
are  ever  ready  to  drop  out.  This  tedious 
soaking  process  seldom  occupies  less  than 
half  an  hour.  In  softening  the  crusts 
the  head  should  be  held  erect  and  the 
basin  containing  the  solution  held  under 
the  chin,  otherwise  the  blood  by  gravity 

1- 


congests  the  tutamina  and  partially  de- 
feats our  purpose.  The  pledget  of  wet 
cotton  should  be  held  between  the 
thumb  and  forefinger  only,  of  the  hand 
on  the  side  to  be  soaked.  If  the  back 
of  the  hand  be  kept  uppermost  and  the 
other  three  fingers  extended,  the  solu- 
tion will  not  run  down  the  arm  nor  wet 
nor  soil  the  patient. 

Having  thoroiighly  removed  the  crusts, 
carefully  dry  the  margins  of  the  lids.  In 
fifteen  minutes'  time  wipe  dry  the  edges 
of  the  lids  and  remove  the  fresh  fluid 
exudation,  which,  if  allowed  to  remain, 
dries  and  forms  new  crusts,  and  under 
these  conditions  all  local  remedial  ap- 
plications are  of  little  use.  This  treat- 
ment must  be  persisted  in,  and  requires 
the  utmost  patience.  The  yellow  oint- 
ment of  Pagenstecher  has  stood  the  test 
of  years,  and  when  this  ointment  will 
not  efl:ect  a  "temporary"  cure — I  use  the 
word  temporary  advisedly — we  must  have 
resort  to  saturated  solutions  of  nitrate  of 
silver  or  even  the  solid  nitrate  itself.  If 
rubbing  a  tiny  scrap  of  the  unguentum 
hydrargyri  oxidi  flavi  (1  grain  to  1 
drachm  of  vaselin)  upon  the  well-washed 
and  thoroughly  dried  edges  of  the  eye- 
lid and  into  the  cilia  does  not  effect  a 
cure,  we  must  have  resort  to  the  nitrate 
of  silver,  brushing  a  strong  solution  care- 
fully upon  the  edges  of  the  lids  and 
around  the  cilia  or  actually  cauterizing 
the  ulcerated  area  around  the  openings 
through  which  the  cilia  project. 

As  we  have  said,  it  is  but  "temporarily 
cured."  Unless  the  cause  of  a  blepha- 
ritis be  removed,  it  will  return.  "We 
have  treated  the  local  condition  and  not 
removed  the  cause.  This,  in  our  experi- 
ence, is  due,  in  the  majority  of  cases, 
to  a  refraction  error  (usually  hyperopia), 
and  is  simply  an  expression  of  functional 
strain.  A  careful  refraction  worked  out 
under  full  atropine  mydriasis,  or  by  the 
37 


578 


BLEPHARITIS.     TEEATMKNT. 


rapid  method  when  the  patient  is  over 
45  years  of  age,  is  the  best  treatment 
for  the  simple,  acute,  and  ordinary  forms 
of  blepharitis  or  blepharadenitis  that  an 
experience  of  a  quarter  of  a  century  now 
suggests. 

The  crusts  are  usually  quite  adherent, 
owing  to  their  composition,  partly  to 
the  sticky  secretion  of  the  Meibomian 
follicles,  and  partly  to  a  varnish-like 
substance  (serum)  which  exudes  from 
the  hair-follicles.  A  weak  solution  of 
bicarbonate  of  soda  softens  and  detaches 
them. 

Best  results  obtained  with  a  solution 
consisting  of  hydrogen  dioxide  and  water, 
equal  parts.  This  accomplishes  the  de- 
sired result  and  does  not  pain  the  eye. 
It  is  to  be  applied  with  a  bit  of  ab- 
sorbent cotton,  dipped  into  the  dioxide 
solution  and  nibbed  along  the  lashes. 
This  should  be  kept  up  until  the  specific 
oxidizing  eifect  is  seen  on  the  scales  or 
crusts,  as  will  be  evidenced  by  the 
effervescence.  The  edges  of  the  crusts 
will  begin  to  separate.  They  are  then  to 
be  dried  with  absorbent  cotton. 

There  is  a  great  advantage  in  using 
this  remedy  in  children;  it  greatly  les- 
sens the  pain  of  the  treatment.  It  is 
also  of  special  value  where  ointments  of 
all  kinds  produce  more  or  less  irritation, 
and  sometimes  cause  an  aggravation  of 
the  symptoms.  S.  C.  Ayres  (Cincinnati 
Lancet-Clinic,  Oct.  23,  '97). 

Large  number  of  cases  of  blepharitis 
treated  with  picric  acid  always  with  good 
results.  Picric  acid  is  used  in  aqueous 
solution  of  strength  5,  8,  and  16  parts 
per  1000,  or  corresponding  strength  made 
with  equal  parts  of  water  and  glycerin. 
The  yellow  coloration  of  the  tissue  which 
it  causes  is  not  a  great  inconvenience. 
It  is  very  necessary  before  applying  the 
picric-acid  solution  to  the  diseased  sur- 
faces to  soften  them  well  and  clear  away 
the  crusts  which  cover  the  eyelids  by 
means  of  a  hot  solution  of  boric  acid  or 
of  ichthyol.  The  applications  are  re- 
newed every  second  day.  In  glandular 
and  ulcerous  blepharitis,  after  having 
cleansed  the  ciliary  border,   opened   the 


little  pustules,  and  extracted  the  eye- 
lashes most  affected,  the  base  of  the- 
ulcers  are  touched  with  a  little  pledget 
of  lint  soaked  in  picric-acid  solution  10' 
to  1000;  then,  after  two  minutes,  the 
whole  of  the  edge  of  the  eyelid  is  treated 
with  a  weaker  solution.  Fage  (Lyon 
M6d.,  Jan.  9,  '98). 

A  50-per-cent.  ointment  of  ichthyol 
may  be  applied  directly  to  the  mucous- 
membrane  as  a  cure  for  blepharitis.  A. 
Peters  and  Darier  (Amer.  Medico-Surg.. 
Bull.,  Sept.  10,  '98). 

During   the   past   year   formalin    em- 
ployed   in    all    cases   of   blepharitis.     A 
tooth-pick    with    a    small    cotton    mop- 
wrapped  on  the  tip  so  that  it  does  not 
take  up  enough  solution  to  run  into  the 
conjunctiva    is    used.      The    solution    is- 
made  of  the  strength  of  Vio  per  cent,  to 
1  per  cent.,  beginning  with  the  weaker.. 
It  must  be  frequently  renewed  or  pre- 
pared at  the  time  of  using,  in  order  to 
insure  uniformity  of  strength.     The  lid 
is  drawn  away  from  the  eyeball.     The 
mop   dipped   in   the   solution   is   rubbed 
gently    along    the    margin    among    the 
lashes  until  all  the  scales  and  crusts  are- 
removed   and   until   the   surface  of   any 
little    pustule    is   rubbed    off.      A    little- 
bland  oil  may  be  applied  afterward,  or 
the  formalin  may  be  used  in  the  oil.    The 
applications  are  made  daily,  if  possible,, 
by  the  physician's  hands.     Otherwise  they 
may  be  made  by  the  patient  at  his  home. 
Correction  of  all  refractive  errors  is  of 
prime  importance;   likewise  the  improve- 
ment of  local  or  general  conditions  which 
may  predispose  the  margins  of  the  lids- 
to   disease    will    invariably   improve   all 
cases  and  will  cure  many  of  them.     H. 
Moulton    (Jour,   of  Amer.   Med.   Assoc.,. 
Sept.  17,  '98). 
Blepharitis  ciliaris  (eczematous)  occurs- 
as  a  concomitant  of  eczema^  seborrhoea, 
and  other  skin  afEections,  and  as  a  com- 
plication of  vaccinia,  syphilis,  and  other 
infectious  processes,  or  may  be  parasitic, 
and  is  to  be  treated  according  to  the  rules 
of   therapy   in    dermatology.      Pediculi 
palpebrarum   looks   like    a   lid   with    a 
double  row  of  cilia  and  readily  yields  to> 
applications  of  unguentum  hydrargyri. 


BLEPHARITIS.     TREATMENT. 


579 


Case  of  vaccination  ulcer  on  the  upper 
lid  of  a  female  adult,  probably  inoculated 
while  washing  a  child,  which  had  re- 
cently been  vaccinated.  Hirschberg 
(Centralb.  f.  prak.  Augen.,  Jan.,  '92). 

Case  of  vaccine  blepharitis.  Lower  lid 
showed  two  ulcerating  patches  at  the 
ciliary  margin,  close  to  the  external 
canthus.  Infection  probably  occurred 
from  contact  with  a  vaccine  pustule  on 
the  arm  of  a  sister.  C.  Zimmennan 
(Archives  of  Ophthal.,  Apr.,  '92). 

Case  of  accidental  vaccinia  of  the  eye- 
lids; latter  oedematous  and  painful,  their 
edges  at  both  outer  canthi  exhibiting  a 
purulent  ulcer  with  indurated  margins. 
Thompson  (London  Lancet,  July  23,  '92). 

Blepharitis  ciliaris  (funinculous)  is  a 
■variety  peculiar  to  no  local  or  reflex  con- 
dition, btit  is  caused,  as  a  rule,  by  an 
infection.  Such  inflammations  follow 
the  usual  course  of  furuncular  inflam- 
mations and  abscesses,  and  the  secretion 
from  the  localized  slough  furnishes  the 
typical  "furuncle  bacillus."  For  this 
reason  alone  the  boils,  or  furuncles,  not 
necessarily  "styes,"  recur,  and  acute 
autoinfeetion  through  the.  mouths  of 
the  Meibomian  follicles  occur  and  recur, 
unless  severe  antiseptic  precautions  are 
rigidly  enforced.  Hot  fomentations  with 
boiled  water,  followed  by  drenchings  with 
borated  or  weak  sublimate  solutions  (1 
to  3000)  are  best.  When  furunculous 
abscesses  are  evacuated  spontaneously 
or  by  the  knife,  a  focus  of  infection  is 
established,  and  we  must  use  dilute 
listerin,  Dobell's  solution.  Seller's  solu- 
tion (tablets),  electrozone,  or  dioxide  of 
hydrogen,  until  complete  healing  has 
taken  place.  Fomentations  are  best 
made  while  the  patient  reclines.  Squares 
of  "spongiopilin"  or  pledgets  of  absorb- 
ent cotton  covered  with  "oil-silk"  are 
most  convenient.  Following  hot  fomen- 
tations, the  eye  should  be  lightly  covered 
and  protected  from  draughts. 

Half-grain  doses  of  sulphide  of  calcium 
in  nill   form   two  or  three   times   a   dav 


after  meals  are  recommended  as  a  pre- 
ventive for  styes.  Sympson  (Brit.  Med. 
Jour.,  Nov.  24,  '88). 

Hydrogen  dioxide  of  special  value  in 
the  treatment  of  blepharitis  marginalis. 
After  the  eye  has  been  cocainized  the 
drug  is  applied  to  the  lid  upon  a  cotton 
tampon.  Daily  sitting.  Ayres  (Amer. 
Jour,  of  Oph.,  Feb.,  '94). 

Successfully  employed  the  above  treat- 
ment  for    the    past    two   years.      Essad 
(Eecueil  d'Ophtal.,  Apr.,  '94). 
Loss  of  cilia  caused  by  destruction  of 
glands  is  seldom  seen,  but  such  loss  of 
cilia  robs  the  eye  of  its  protection  against 
light.    Cilia  generally  grow  again  unless 
the  edges  of  the  lids  are  sclerosed  and 
deformed  with  cicatrices  from  neglected 
ulcerations  about  the  mouths  of  the  hair- 
follicles. 

Closure  of  the  puncta  laerymalia  is  a 
most  serious  complication.  All  careful 
operators  take  great  pains  to  cleanse  the 
cilia,  especially  the  superior  ones  in  any 
case.  It  is  unsafe  to  operate  with  bleph- 
aritis present,  as  the  secretion  would  in- 
fect the  wound. 

In  phlegmonous,  or  erysipelatous, 
blepharitis  ciliaris  with  abscess  of  the 
upper  lids,  and  in  cases  of  ecchymosis  or 
other  swellings,  these  should  be  evacu- 
ated, the  eyeball  being  cut  into. 

A  fact  worth  noting  is  that  blepharitis 
ciliaris  is  seldom  found  accompanying 
myopia. 

If  blepharitis  ciliaris  is  a  symptom  of 
functional  strain  of  reflex  eye  origin, 
headaches  are  seldom  present.  If,  on  the 
contrary,  headaches  are  the  one  symp- 
tom, blepharitis,  or  blepharadenitis,  is 
generally  conspicuous  by  its  absence. 

If  one  eye  be  used  more  than  the 
other,  or  if  one  eye  be  not  used  at  all, 
more  or  less  blepharitis  ciliaris  will  likely 
indicate  the  amount  of  strain. 

Blepharadenitis  is  only  an  aggravated 
subacute  or  chronic  form  of  blepharitis 
ciliaris,    in    which    the    mouths    of   the 


580 


BLEPHAKITIS. 


BORACIC  ACID. 


Meibomian  follicles  have  become  closed 
and  the  lining  membrane  of  the  glands 
has  become  subacutely  or  chronically 
inflamed.  Eetention-cysts  and  abscesses 
with  pyogenic  membranes  secrete  pus 
from  granulating  sacs  and  deform  the 
lid. 

Unless  every  particle  of  diseased  gland 
with  its  pyogenic  membrane  be  carefully 
removed,  recurrence  will  take  place,  and 
injury  to  the  tarsal  cartilage  will  cause 
deformit3^  Epiphora,  entropium,  and 
ectropium  will  ensue,  and  with  them 
what  is  best  described  as  "wrinkled  lid" 
will  remain  as  a  permanent  source  of 
trouble,  and  rub  its  irregular  siirfaces 
over  a  cornea  doomed  to  destruction 
from  irritation  and  ulceration. 

We  can  recall  the  time  spent  years 
ago  in  fighting  blepharitis  and  blepha- 
radenitis  until  its  true  ease  was  recog- 
nized and  understood.  At  present,  and 
in  the  light  of  modern  ophthalmic 
surgery,  we  recognize  in  blepharitis,  or 
blepharadenitis,  only  a  symptom  which 
in  a  general  way  promptly  yields  to 
treatment  when  we  remove  the  cause. 
The  elimination  of  the  latter  as  promptly 
brings  relief  in  other  directions:  not 
only  by  improving  the  vision,  but  also 
by  curing  life-long  headaches  and  other 
neuroses. 

Charles  S.  Tuenbull, 

Philadelphia. 

BORACIC  ACID.  —  Boracic,  or  boric, 
acid  appears  in  the  form  of  white,  trans- 
lucent or  lustrous  scales  or  needles,  and 
is  usually  prepared  by  adding  hydro- 
chloric acid  to  a  hot  solution  of  borax 
(sodium  borate);  when  comparatively 
fresh  it  exhales  a  faint  odor  of  benzoin. 
It  has  a  warm,  acrid  taste;  acid  reac- 
tion; and  is  freely  soluble  in  alkaline 
media,  in  oils,  and  in  chloroform;  1  to 
3   in   alcohol;    1   to   15   in  boiling  and 


about  1  to  25-50  in  cold  water.  The 
solubility  in  cold  water  varies  so  greatly 
with  different  specimens  as  to  seem  un- 
accountable, but  doubtless  depends  upon 
the  source  of  the  acid,  the  mode  of  its 
manufacture,  and  the  resultant  purity 
or  impurity.  In  1889  Catanis  proposed 
to  render  the  acid  more  soluble  by  mix- 
ing 120  parts  with  10  of  calcined  mag- 
nesia and  750  of  water,  whereby  a  con- 
siderable proportion  of  the  former  is  in 
solution  in  excess. 

From  the  fact  that  boracic  acid  forms 
borates  with  most  of  the  alkaloids,  it 
has  been  advised  that  they  be  employed 
when  the  acidity  of  the  drug  is  to  be 
feared. 

Preparations  and  Dose. — Boracic  acid, 
5  to  15  or  30  grains. 

Borate  of  ammonium,  10  to  20  grains. 

Borate  of  sodium  (borax),  15  to  30 
grains. 

Borate  of  zinc,  for  external  use  only. 

Physiological  Action,  —  Boracic  acid 
and  all  its  salts  are  deemed  more  or  less 
antiseptic,  and  the  former  has  attained 
special  repute  because  of  its  inexpensive- 
ness,  general  harmlessness,  and  unirri- 
tating  character.  But  purity  is  always 
a  matter  to  be  carefully  considered,  both 
as  regards  external  and  internal  use. 
It  is  not  so  commonly  employed  as 
an  internal  medicament,  perhaps,  as  the 
sodium  salt,  becaiTse  of  its  somewhat 
pimgent  and  acid  taste,  and  partly  be- 
cause it  is  deemed  less  convenient  to 
prescribe  in  aqueous  mixtures.  In  ex- 
cessively large  doses,  however,  both  it 
and  the  salts  depress  the  spinal  centres, 
and  may  prodiice  progressive  loss  of 
voluntary  and  reflex  activity  without 
affecting  nerve  or  muscle.  Schiff  is  re- 
sponsible for  the  statement  that  boracic 
acid,  when  locally  applied  to  nerves, 
causes  the  part  to  lose  the  power  of 
oris'inatins;,  but  not  of  transmitting,  im- 


BORACIC  ACID.     PHYSIOLOGICAL  ACTIOX. 


581 


pulses;  so  that,  if  the  galvanic  current 
be  applied  to  the  part  of  the  nerve  which 
has  been  exposed  to  the  drug,  no  mus- 
cular contractions  result;  but,  if  the 
poles  be  placed  above  this  part,  the  distal 
muscles  respond  at  once  (Wood).  Some 
persons,  however,  appear  to  be  able  to 
bear  with  impunity  almost  fabulous 
doses  of  the  drug,  which  evidences  that 
its  exact  phj'siological  status  is  undeter- 
mined and  chiefly  a  matter  of  specirla- 
tion. 

In  doses  of  30  to  60  grains  often  re- 
peated, boracic  acid  is  likely  to  induce 
nausea  and  vomiting,  and,  if  persisted  in 
(or  even  in  large,  single  doses),  to  give 
rise  to  concatenation  of  s3"mptoms  in- 
dicating gastro-enteritis. 

Bruswanger  (von  Eenterghem  and 
Laura)  remarked  diuresis  with  increased 
desire  to  urinate  to  follow  doses  of  from 
30  to  120  grains;  he  believes  that  the 
acid  is  eliminated  through  the  kidneys 
as  an  alkaline  borate,  in  which  conclu- 
sion Eabuteau  concurs.  Polli,  however, 
does  not  believe  that  the  acid  undergoes 
any  alteration,  but  that  it  is  passed  un- 
changed. H.  C.  Wood  states  that  it  is 
rapidly  eliminated  with  the  urine,  and 
also  escapes  with  the  perspiration,  saliva, 
and  fasces.  It  increases  elimination  of 
urea,  as  well  as  the  flow  of  urine. 

Untoward  Effects.  —  Though  Gau- 
cher insists  that  it  would  require  2  ^/^ 
ounces,  per  daj',  administered  for  several 
days  in  succession,  to  produce  dangerous 
symptoms,  his  confidence  is  not  sup- 
ported by  general  evidence,  for  it  has 
been  known,  in  considerably  smaller 
doses,  to  induce  parenchymatous  ne- 
phritis. This  is  especially  true  of  its 
sodium  salt,  which  is  a  dangerous  rem- 
edy as  regards  most  renal  maladies,  and 
seems  to  possess  the  power  of  provoking 
malignant  degeneration  where  a  morbid 
process  has  already  been  set  up  in  the 


kidne3's.  George  T.  Welch  reports  two 
eases  in  which  the  application  of  tam- 
pons of  powdered  boracic  acid  produced 
general  toxic  symptoms:  in  one  case  the 
skin  had  a  dried,  "charred"  appearance, 
and  in  the  other  there  was  collapse;  in 
both  there  was  verj'  marked  coolness  of 
the  vagina.  Mododewkow  chronicles  a 
death  from  washing  the  stomach  with  a 
2  Va-per-eent.  solution;  but  there  are 
no  valid  grounds  for  believing  the  me- 
dicament had  anything  to  do  with  the 
fatality.  Lemoine  observed  a  bluish-gray 
line  on  the  gums,  as  if  from  lead  poison- 
ing, in  a  case  of  epilepsy  to  which  so- 
dium borate  had  been  given.  Bran- 
thomme  also  reports  two  cases  suffering 
with  carbuncle  who  were  poisoned 
through  the  daily  application  of  30 
grains  of  the  acid.  The  symptoms  had 
no  relation  to  the  malady,  for  in  the 
one  case  was  restlessness  and  a  feeling 
of  burning  under  the  whole  skin,  in- 
tense thirst,  a  temperature  of  38.8°  C, 
and  the  body  covered  with  red  patches; 
in  the  second  case  an  eczematous  erup- 
tion, anorexia,  and  insomnia  appeared. 
In  both  cases  the  untoward  symptoms 
subsided  immediately  on  withdrawal  of 
the  acid  applications.  Wbat  is  said  of 
the  acid  will,  in  a  general  way,  apply  to 
its  salts. 

Two  eases  of  profuse  dermatitis  fol- 
lowed the  administration  of  boracic  acid. 
In  the  first  case  the  condition  developed 
on  three  separate  occasions  following  the 
administration  of  the  drug.  The  patient 
finally  died  some  time  after  the  last 
attack  in  uraemia  following  an  alcoholic 
debauch.  The  manifestations  in  the  sec- 
ond case  were  similar  to  those  in  the 
first  in  that  they  followed  prolonged  ad- 
ministration of  boracic  acid.  Two  forms 
of  borax  poisoning  must  be  distin- 
guished: one  in  which  a  large  quantity 
of  the  drug  is  rapidly  absorbed  from 
the  alimentary  canal,  from  some  serous 
or  other  cavity,  or  from  an  extensive  raw 


582 


BOKACIC  ACID.     THERAPEUTICS. 


surface,  causing  vomiting  and  diarrhoea, 
general  depression,  skin-rashes,  and  par- 
tial paralysis  of  the  nervous  and  mus- 
cular systems;  occasionally  death.  The 
other  class  results  from  the  administra- 
tion of  boracic  acid  or  borax  in  compara- 
tively small  doses  for  long  periods.  In 
some  of  these  cases  the  kidneys  are  dis- 
eased, in  others  albumin  appears  in  the 
urine,  and  in  several  fatal  cases  uremic 
symptoms  were  described.  E.  B.  Wild 
(Lancet,  Jan.  1 ,  '99). 

Therapeutics.  —  The  scope  of  boracic 
acid  as  an  antiseptic  is  very  wide,  for 
it  has  been  employed  in  almost  every 
conceivable  surgical  process:  as  a  de- 
tergent for  painful  and  suppurating 
wounds  and  ulcers;  as  a  basis  for  in- 
jections and  ointments  of  all  kinds;  in 
collyria;  as  an  insufflation  powder  for 
the  ear;  to  wash  out  irritable  bladders 
and  dilated  stomachs;  as  an  application 
to  skin  maladies. 

In  suppuration  of  the  middle  ear 
packing  of  the  meatus  Avith  pure,  im- 
palpably-powdered  boracic  acid  is  to  be 
preferred  to  insufflation;  this  method  is 
safe  if  the  ears  be  inflated  daily.  Seely 
(Weekly  Med.  Review,  Mar.   10,  '89). 

Otorrhea  is  one  of  the  most  difficult 
to  cure  of  all  conditions  affecting  the 
ear.  Boracic  acid  perfectly  meets  the 
indication  of  a  non-iiTitant  antiseptic. 
Bacon  (Amer.  Ther.,  June,  '95) . 

The  use  of  borax  or  boric  acid  as  a 
preservative  in  butter  and  cream  in  the 
quantities  specified  in  the  recommenda- 
tions of  the  English  Commission  is  justi- 
fied both  b}'  practical  results  and  by 
scientific  experimentation.  The  dusting 
of  the  surfaces  of  hams  and  bacon  which 
are  to  be  transported  long  distances 
with  borax  or  boric  acid,  not  exceed- 
ing 1.5  per  cent,  of  the  weight  of  the 
meat,  is  effective,  and  not  objectionable 
from  a  sanitar}'  standpoint.  Meat  thus 
dusted  with  borax  or  boric  acid  does 
not  become  slimy,  because  the  preserva- 
tive thus  used  prevents  the  growth  of 
aerobic,  peptonizing  micro-organisms. 
V.  C.  Vaughan  and  W.  H.  Veenboer 
(Amer.  Medicine,  March  15,  1902). 


Boracic  acid  has  been  very  extensively 
employed  in  the  treatment  of  eye  mala- 
dies. Bourgeois,  of  Eheims,  recommends 
it  for  phlyctenular  and  granular  con- 
junctivitis; Smith,  of  Chattanooga,  as 
a  wash  for  ophthalmia  neonatorum; 
Dimissas  introduces,  every  night,  an 
ointment  of  boracic  acid  between  the 
ej^elids  after  operating  for  cataract;  but 
iSToyes  declares  the  drug  should  be  used 
with  caution,  and  of  a  strength  of  not 
more  than  1  per  cent.,  since  he  has  seen 
a  diffuse  keratitis  develop  from  a  4-per- 
cent, solution. 

It  is  probable,  however,  that,  when 
untoward  results  accrite  to  the  use  of 
a  4-per-cent.  solution  in  the  eye,  even 
after  cataract  extraction,  such  is  due  to 
the  quality  of  the  acid  employed. 

In  measles,  too,  frequent  bathing  of 
the  eyes,  nose,  and  ears  with  warm 
boracic-acid  solution  is  to  be  recom- 
mended as  beneficial  and  comforting  to 
the  patient. 

This  drug  has,  also,  been  employed  in 
the  treatment  of  chancroid  as  a  dust- 
ing-powder; as  an  injection,  and  also 
internally  administered,  in  cystitis;  in 
naso-pharyngeal  catarrh,  especially  the 
troitblesome  form  seldom  seen  except  in 
children;  in  chronic  constipation,  by 
applying  the  dry  powder  direct  to  the 
rectal  mucosa;  in  watery  solution  and 
in  ointment  form  to  the  urethra  for 
gonorrhoea;  in  the  form  of  ointment  to 
the  pustules  of  variola  to  prevent  pit- 
ting, etc. 

In  spite  of  the  reputation  accruing  at 
one  time,  it  is  doubtful  if  any  material 
benefit  is  ever  derived  from  the  use  of 
this  acid  in  any  but  the  milder  and  less 
stubborn  varieties  of  skin  disease.  It 
may,  however,  prove  a  valuable  adjunct 
to  other  treatment. 

AVlien    there    is    a    profuse    discharge 
from  an  eczematous  patch,  I  direct  the 


BORACIC  ACID.    AMMONIUM  BORATE. 


583 


latter  to  be  washed  with  a  weak  solu- 
tion   of   boraeic   acid,    then    dried    with 
muslin    bags    containing    the    dry    acid 
duly   incorporated   with   finely-powdered 
starch.     Malcolm  Morris   (Practitioner). 
Similar  procedures  have  been  recom- 
mended    by    many    authors.      Gaucher, 
■corroborated  by   Sevestre,   Compy,  and 
Cadet  de  Gassicourt,  however,  goes  fur- 
ther, and  declares  that  he  has  secured 
rapid  recovery  in  eczema,  and  also  in 
contagious  impetigo,  by  employing  it  in 
glycerole  of  starch,  1  to  30;    he  insists 
that  this  combination  offers  all  the  good 
to  be  obtained  from  oil  of  cade  without 
any  of  the  disadvantages  of  the  latter. 

In  the  erysipelas  of  the  newborn 
Lemaine  lauds  this  drug  above  all 
others.  He  holds  that  the  malady  is 
derived  from  an  attenuated  puerperal 
septicemia  in  the  mother,  and  so  directs 
the  application  of  hot  solutions  of  the 
acid,  and  subcutaneous  injections  of  the 
same,  cooled,  twice  daily. 

Matigon,  of  Bordeaux;  Mackenzie  and 
Abbott,  of  London,  as  well  as  many 
others,  express  a  decided  preference  for 
boraeic  acid,  or  for  the  tetraborate  of 
sodium  (this  latter  being  merely  a  com- 
bination of  boraeic  acid  and  borax), 
above  all  other  medicaments  for  the  pur- 
pose of  preparing  solutions  intended  to 
be  used  in  the  pleural  cavity,  especially 
after  pnetimotomy  or  aspiration. 

In  1890  Edmund  Andrews,  of  Chicago, 
published  the  results  accruing  to  a  series 
of  experiments  undertaken  to  determine 
the  value  of  the  acid  as  an  antiseptic. 
He  placed  2  drachms  of  fresh  pork  mus- 
cle in  each  of  a  series  of  bottles,  and 
added  different  percentages  up  to  com- 
plete saturation  of  acid  solution.  The 
result  seemed  to  prove  that  even  the 
strongest  solution  cannot  inhibit  the 
growth  of  mycelia,  and  further  that  no 
species  of  germs  can  thereby  be  entirely 
prevented   from  growing;    that  boraeic 


acid  only  covers  a  raw  surface  with  a 
moisture  that  is  not  distinctly  antiseptic, 
but  is  nevertheless  rather  unfavorable  to 
the  growth  of  bacilli.  Unfortunately 
for  Dr.  Andrews's  conclusions,  however, 
they  are  based  upon  incomplete  experi- 
ments, and  consequently  imperfect  data. 
As  has  before  been  remarked,  the  acids 
of  commerce  vary  greatly  according  to 
source  and  mode  of  manufacture;  con- 
sequently a  series  of  experiments  should 
have  been  made  with  different  products. 
Moreover,  the  evidence  is  now  over- 
whelmingly positive  that  a  moderately 
pure  boraeic  acid  is  antiseptic,  though 
only  in  slight  degree;  but  it  commends 
itself  to  the  medical  man  especially  be- 
cause it  is  practically  odorless  and  in- 
nocuous. 

Internally  the  acid  appears  to  have 
been  successfully  employed  in  a  variety 
of  maladies.  Gaucher  administered  from 
7  to  20  grains  daily  to  a  number  of 
patients  suffering  with  pulmonary  tuber- 
culosis, and  claims  that  both  the  local 
and  general  symptoms  were  improved, 
while  the  sputiim  lost  its  foetid  charac- 
ter; it  had,  however,  no  action  upon  the 
bacilli. 

Tertschinsky  gave  boraeic  acid  in  240 
cases  of  enteric  fever  in  doses  of  from 
13  to  15  grains  three  or  four  times  daily, 
with  only  9  resulting  fatalities.  Kee- 
gan  also  successfully  employed  it  in  a 
considerable  number  of  cases. 

Ammonium  Borate. 

This  may  be  prepared  by  dissolving  1 
part  of  boraeic  acid  in  3  parts  of  hot 
liquor  ammonia  of  a  specific  gravity  of 
0.960,  and  cooling  to  crystallization.  It 
appears  as  white  or  transparent  eight- 
sided  crystals,  with  strong  ammoniaeal 
odor;  soluble  in  the  ratio  of  1  to  12  in 
cold  water.  It  is  employed  both  topically 
and  internally  in  cystitis,  and  internally 
in  renal  diseases,  where,  in  either  case, 


584 


BORACIC  ACID.    BORAX.    THERAPEUTICS. 


there  is  an  excess  of  acid  or  earthy  phos- 
phates. The  value  of  the  remedy,  how- 
ever, is  doubtful,  though  in  some  few 
instances  it  appears  to  afEord  slight  re- 
lief. It  has  been  tried  in  epilepsy  also, 
but  with  negative  results. 

Sodium  Biborate;  Sodium  Borate; 
Borax. 

This,  the  best  known  and  most  gen- 
erally employed  internally  of  all  the 
borate  salts,  has  for  many  centuries  been 
alternately  lauded  and  condemned  by  the 
medical  profession,  though  it  has  always 
retained  a  status  in  domestic  pharmacy 
and  therapeutics.  As  found  in  the 
shops,  it  appears  in  colorless  transparent 
monoclinic  prisms,  shining,  odorless,  and 
effervescent  in  dry  air.  It  is  soluble  in 
half  its  weight  of  boiling  water,  1  to  16 
in  cold  water;  insoluble  in  alcohol,  but 
very  soluble  in  glycerin  and  fats. 

The    addition   of   a   small    amount   of 
sugar  greatly  increases  the  solubility  of 
borax;     it   will   also   rapidly    liquefy    a 
solution   of  gum   arable   which   has  be- 
come   gelatinous    from    the    presence   of 
borax.    Editorial  (Amer.  Medico-Surgical 
Bulletin,  Oct.  25,  '97). 
It  also  has  a  faint,  sweetish  taste  and 
alkaline  reaction;   in  solution  it  absorbs 
carbonic  acid  and  dissolves  fibrin,  albu- 
min, casein,  and  uric  acid. 

As  a  general  rule,  sodium  borate  be- 
liaves   like   the   alkalies,   and,  therefore, 
it    should    not   be    associated    with    the 
salts  of  the   alkaloids.     In  mixtures   of 
this  kind  the  patient  is  likely  to  take 
most  of  the  alkaloid   in   the  last   dose, 
with  harmful  effect.    A.  Dujardin  (Union 
Med.  du  Nord-est,  Nov.,  '91). 
Therapeutics.  —  As  an  application  to 
mucous  membranes,  because  of  its  mildly 
antiseptic  and  soothing  effects,  borax  in 
solution  is  almost  without  a  peer;  many 
maladies   make   most   happy   recoveries 
under  its  use  that  with  other  remedies 
of  more  pronounced  astringent  or  irri- 
tant   character    prove    most    vexatious. 


Especially  is  this  true  of  some  of  the 
lesser  diseases  of  the  eye  and  naso- 
pharynx, the  milder  forms  of  conjunc- 
tivitis, certain  forms  of  rhinitis,  ulcer- 
ative stomatitis,  etc.  Sodium  borate  in 
camphor-water  secures  a  pleasant,  harm- 
less, and  grateful  collyrium  that  may 
advantageously  be  employed,  either  alone 
or  in  connection  with  other  remedies,  in 
most  inflammatory  conditions  of  the  eyes. 

In  ulcerative  stomatitis,  swab  with 
water  acidulated  with  a  few  drops  of 
acetic  acid  and  follow  by  painting  with 
borax  (1  part)  dissolved  in  glycerin  (8 
parts).  Garrigues  (Med.  News,  Oct.  1, 
'92). 

In  atrophic  rhinitis  solution  of  so- 
dium borate  in  glycerin,  sufficiently 
diluted  with  water,  may  be  sprayed  into 
cavities;  glycerin  prevents  fonnation  of 
crusts;  sodium  borate  prevents  decom- 
position of  exudation.  Musehold  (Revue 
Inter,  de  Med.  et  de  Chir.,  Apr.  25,  '95). 

There  can  be  no  doubt  of  the  value  of 
boracic  acid  and  borax  as  local  applica- 
tions in  aphthous  ulcerations,  diphtheria, 
and  other  inflammations  of  the  mouth, 
in  which  the  crystals  of  the  sodium  salt 
may  be  permitted  to  slowly  dissolve  on 
the  tongue.  H.  0.  Wood  ("Therapeutics: 
its  Principles  and  Practice,"  ninth  ed.). 

Sodium  borate  is  frequently  employed 
against  stomatitis  and  against  aphthous 
ulcerations  of  the  mouth,  as  in  ptyalism, 
glossitis,  anginas,  etc.  It  is  evident  that 
the  antizymotic  property  of  sodium 
borate  is  the  deterring  influence.  Von 
Renterghem  and  Laura  (Dosimetric  Med. 
Review,  Dec,  '97) . 

The  last  authors  quoted  very  justly 
believe  that  this  medicament  offers  cer- 
tain advantages  in  the  treatment  of  some 
skin  diseases,  since  it  may  be  employed 
topically  to  dissolve  the  pellicles  of  the 
epidermis  joined  together  by  sebaceous 
matter,  thereby  acting  as  a  detergent; 
in  pruriginous  or  eczematous  eruptions 
due  to  the  accumulation  of  products  of 
the  sudoriparous  glands  the  salt  is  often 
most  effective. 


BORACIC  ACID.     BORAX.     THERAPEUTICS. 


585 


Congenital  ichthyosis  in  a  child  treated 

by  washes  of  sodium  borate.     Shenvell 

(Jour.  Cut.  and  Genito-Urin.  Dis.,  Sept., 

'94). 

In  erysipelas  Sevestre  employs  baths 

at  93.2°  P.  containing  16  ounces  of  so- 

dinm  borate,  which,  he   claims,  lowers 

the  temperature  and  tends  to  heal  the 

eruption. 

In  1894  Ciaglinski  and  Hewelki  de- 
scribed a  case  of  black  tongue  present- 
ing a  patch  of  mold  extending  as  far 
back  as  the  ciicumvallate  papillte  that 
contained  black  pigment  and  closely 
resembled  the  fungus  known  as  Mucor 
rhizopodiformis.  By  means  of  borax 
washes  the  tongue  became  clean  in  a 
couple  of  days. 

Both  borax  and  boraeic  acid  have  been 
recommended  as  injections  for  an  in- 
flamed bowel,  but  their  utility  cannot  be 
very  pronounced. 

In  severe   cases  of  infantile  diarrhoea 
daily   irrigation   of   the  larger   bowel   is 
most  beneficial  during  the  height  of  the 
disorder.     I  employ   borax:     1    drachm 
to  a  pint  of  warm  water.     Carter  (Pro- 
vincial Med.  Jour.,  May  1,  '94). 
That  sodiiim  borate  has  some  action 
upon  the  central  nervous  system  is  ap- 
parent, but  this  is  so  ill  understood  that 
it  is  impossible  to  formulate  any  definite 
physiological  basis  for  its  internal  ad- 
ministration.    It  has  been  empirically 
recommended  for  a  multitude   of   dis- 
eases, including  locomotor  ataxia,  paral- 
ysis agitans,  cholera,  etc. 

Have  used  sodium  borate  with  excel- 
lent results  in  paralysis  agitans.  Sacaze 
(Bull,  de  la  Soc.  de  Med.  Mentale  de 
Belgique,  Mar.,  '94). 

Borax  in  doses  of  80  to  90  grains  daily 
is  to  be  highly  recommended  as  a  proph- 
ylactic against  cholera.  During  the 
epidemic  in  Italy  during  1864-65  none 
of  the  villagers  employed  in  the  borax 
works  were  affected,  while  in  a  village 
in  close  proximity  one-third  of  the  in- 
habitants died.  I  opine  that  the  drug 
kills  the  germs  in  the  alimentary  canal. 


Cyon     (Compt.-Rend.    Acad.    Sci.,    xcix, 
149). 

Looking  at  the  drug  from  the  stand- 
point of  the  author  last  quoted,  and 
admitting  its  mildly  antiseptic  property, 
— which  are  undoubted, — it  is  easy  to 
discover  the  reasoning  that  has  led  to 
its  use  in  septic  diseases.  So,  too,  the 
solvent  action  of  the  borates  as  regards 
uric  acid,  and  their  tendency  to  elimi- 
nate urea,  explain  why  borax  often 
yields  gratifying  results  when  employed 
in  uric-acid  lithiasis;  but  it  should 
always  be  most  freely  diluted  with  water. 
Another  peculiarity  of  borax,  also  un- 
defined, is  its  affinity  for  the  genito- 
urinary organs.  In  some  cases  it  relieves 
uterine  haemorrhage  with  surprising 
promptness:  an  action  that  can  only  be 
explained  by  reflex  through  the  nervous 
system. 

But  it  is  in  epilepsy  that  borax  has 
been  most  exploited  in  recent  years 
though  its  use  in  this  direction  is  by 
no  means  new;  and  for  a  brief  period  it 
was  thought  an  absolute  panacea  had 
been  discovered.  But  H.  C.  Wood,  who 
tried  it  in  a  number  of  cases,  succeeded 
only  in  inducing  marked  gastro-intesti- 
nal  irritation  in  every  patient. 

In  order  to  avoid  gastric  and  skin 
troubles  by  reason  of  large  doses,  I  would 
suggest  the  borax  be  given  with  consid- 
erable doses  of  naphthol  or  bismuth  salic- 
ylate. Fere  (La  Semaine  Med.,  Feb.  4, 
'92). 

Of  twenty-five  cases  one  was  cured  and 
all  relieved  but  six.  Treatment  was  con- 
tinued from  one  to  seven  months.  Dijoud 
(Lancet,  July  18,  '92). 

Borate  of  soda  is  superior  to  potassium 
bromide  in  symptomatic  epilepsy,  but  of 
less  value  in  nervous  epilepsy.  Mariet 
(Le  Prog.  M6d.,  Oct.  10,  '92). 

The  prolonged  exhibition  of  the  salt 
may  induce  cutaneous  troubles,  consist- 
ing principally  of  seborrhoeic  eczema  of 
the  scalp.  The  hair  is  shed,  but  grows 
again   when    the   administration    of   the 


586 


BORACIC  ACID. 


BRIGHT'S  DISEASE. 


borax  is  stopped.  Fere  (Lancet,  Dee.  23, 
'92). 

Borax  as  a  means  of  relief  seems  to 
have  established  for  itself  a  fixed  and 
permanent  position.  Gray,  Pritehard, 
and  Shultz  (Annual  of  the  Univ.  Med. 
Sci.,  vol.  ii,  '94). 

Borax  is  a  useful  remedy  against  con- 
vulsive attacks  of  an  epileptic  character. 
Angelucci  and  Pieraccini  (Lo  Sperimen- 
tale.  No.  I,  '94). 

Borax  given  alone  is  disappointing  in 
some  respects,  but  given  with  the  bro- 
mides its  action  is  much  better  and  the 
combination  superior  to  either  drug 
alone.  Alexander  (Liverpool  Medico- 
Chir.  Jour.,  July,  '94) . 

On  the  whole,  borax  is  of  no  value  in 
epilepsy.  Lui  and  Guicciardi  (Revista 
Speri.  di  Fren.  e  di  Med.  Legale,  etc., 
Sept.,  '95). 

It  may  be  imagined  that  iinder  certain 
circumstances  borism  may  give  rise  to 
accidents  every  whit  as  grave  as  those 
of  bromism,  with  the  difference  that 
those  arising  in  the  kidneys  are  more 
insidious  and  more  difficult  to  remove. 
This  fact,  more  than  all  else,  perhaps, 
has  led  to  a  very  general  abandonment 
of  the  drug,  though  a  few  still  persist  in 
its  iTse,  with  more  or  less  varying  results 
that  apparently  depend  upon  the  toler- 
ance exhibited  by  the  individual  patient. 

Teteaboeate  of  Sodium. — Boymond, 
in  1893,  called  the  attention  of  the 
Societe  de  Therapeutique  to  a  new 
product  which  he  termed  "boro-borax," 
and  for  which  was  likewise  claimed  anti- 
septic properties  superior  to  those  of 
corrosive  sublimate.  This  is  simply  the 
tetraborate  of  sodium  in  solution,  and 
appears  to  be  a  trifle  more  powerful  than 
a  corresponding  solution  of  boracic  acid. 
A  solution  may  be  extemporaneously 
made  by  adding  26  drachms  of  boracic 
acid  to  a  quart  of  distilled  water  and 
then  neutralizing  by  sodium  borate. 

Zinc  Borate,  or  Tetraborate. 

This  is  an  amorphous,  white  powder 


obtained  by  the  interaction  of  zinc  sul- 
phate and  sodium  borate  in  hot  water. 
Like  all  new  agents  of  its  class,  when 
first  introduced  wonderful  antiseptic 
power  was  claimed  for  it,  but  this  ap- 
pears to  have  not  been  sustained.  It  is 
freely  soluble  in  acid  media  only;  has 
been  employed  as  a  dusting-powder  for 
raw  surfaces;  but  it  does  not  appear  to 
offer  any  advantages  over  boracic  acid, 
while  its  almost  insoluble  character  in- 
hibits its  use  in  conditions  where  the 
latter  is  always  available. 

BRAIN.  See  Ceeebeal  Abscess, 
Ceeebeal  H^moeehage,  Encephali- 
tis;  Head,  Injueies  of,  etc. 

BREAST.    See  Mammaet  Gland. 

BRIGHT'S  DISEASE. 

Acute  Uephritis. 

Definition.  —  An  acute  inflammation 
of  the  kidnej's,  and  either  of  a  mild, 
severe,  or  grave  character.  It  may  be 
more  or  less  diffuse  in  nature.  Three 
varieties  of  acute  renal  disease  are  de- 
scribed by  Delafield  under  the  term 
acute  Bright's  disease:  (1)  acute  degen- 
eration of  the  kidneys,  (2)  acute  exuda- 
tive nephritis,  and  (3)  acute  productive 
nephritis. 

Symptoms. — The  onset  is  sudden,  as  a 
rule,  but  varies  with  the  exciting  cause 
of  the  nephritis.  Chilliness,  nausea  and 
vomiting,  pain  in  the  back,  and,  within 
twenty-four  hours,  dropsy  are  seen  in 
some  cases.  Children  are  subject  to  con- 
vulsions (urssmic),  and  in  severe  cases 
adults  are  no  less  liable.  Fever  may  be 
present,  but  it  is  neither  constant  nor 
high.  The  early  appearance  of  cedem- 
atous  puffiness  of  the  eyelids  and  face, 
and  of  pallor  of  the  skin,  is  character- 
istic. Soon,  and  sometimes  at  first,  a 
swelling   occurs   about    the    ankles    and 


BRIGHT'S  DISEASE.     ACUTE  NEPHRITIS.     SYMPTOMS. 


587 


legs,  and  in  severe  cases  dropsy  involves 
the  whole  body.  The  scrotum,  penis,  or 
labia  may,  in  such  cases,  become  enor- 
mously distended,  the  skin  presenting  an 
almost  translucent  appearance. 

Often  local  symptoms  are  absent,  as 
pain  and  tenderness  in  the  lumbar  re- 
gion; they  are  never  marked.  Micturi- 
tion may  be  frequent  and  accompanied 
by  a  slight  burning  and  vesical  tenesmus, 
■due  to  the  concentrated  urine.  In  very 
severe  dropsy  the  tense,  dry  skin  may 
become  sensitive  or  even  painful  on 
pressure.  Bodily  movements  are  often 
painful  and  difficult  in  cases  of  marked 
anasarca.  Urgemia  may  be  heralded  by 
intense  headache  and  backache. 

A  urinary  examination  is  always  nec- 
essary, as  in  mild  cases  the  renal  con- 
dition may  be  overlooked.  There  may 
be  no  further  symptoms  than  a  general 
malaise. 

The  urine  in  acute  nephritis  furnishes 
■distinctive  characteristics.  The  total 
quantity  passed  in  twenty-four  hours 
is  diminished,  and  may  even  be  very 
■scanty,  varying  from  5  to  25  ounces 
(150  to  740  cubic  centimetres).  There 
may  be  suppression  in  cases  of  toxic 
■origin,  when  an  acute  degeneration  or 
necrosis  of  the  renal  epithelium  occurs, 
■and  in  the  very  severe  exudative  inflam- 
mations. 

The  specific  gravity  is  early  increased 
to  1025  or  more,  though  later  it  may  fall 
to  1015  or  1010.  The  color  is  darker 
than  normally  and  is  usually  smoky 
red,  or  reddish  brown,  according  to  the 
amount  of  blood  contained.  A  more  or 
less  abundant  flocculent  sediment  ap- 
pears on  standing,  if  the  normal  mor- 
phological constituents  are  present  in 
great  quantity. 

Some  red  blood-corpuscles  and  renal 
•epithelium  are  found  microscopically, 
together  with  the  characteristic  hyaline. 


blood,  and  epithelial  tube-casts.  The 
urine  is  acid  in  reaction,  and  on  boiling 
throws  down  a  thick,  curdy  precipitate 
of  albumin,  which  varies  in  weight  from 
V4  to  1  per  cent.  The  urea  is  dimin- 
ished. 

There  may  also  be  other  symptoms 
during  the  course  of  acute  Bright's  dis- 
ease, as  those  of  hydrothorax,  ascites, 
and  hydropericardium,  in  cases  in  which 
great  general  oedema  is  present.  The 
first-named  condition  is  bilateral  and 
gives  rise  to  dyspnoea;  the  second  in- 
creases the  dyspnoea  by  pressing  the 
diaphragm  upward;  and  the  last  im- 
pedes the  heart's  action.  Striimpell 
describes  a  form  of  pneumonia  that 
sometimes  develops  in  severe  cases  of 
acute  nephritis, — a  "stiff  inflammatory 
oedema," — midway  between  lobar  and 
broncho-  pneumonia.  There  may  also 
be  oedema  of  the  conjunctiva,  soft  pal- 
ate, and  larynx. 

The  pulse  is  often  hard  and  tense, 
and,  though  slow  at  first,  it  may  become 
accelerated  later.  Cardiac  hypertrophy 
may  be  present  in  a  slight  degree.  The 
aortic  second  sound  is  accentuated. 
Epistaxis  appears  occasionally,  and  sub- 
conjunctival hsemorrhages  sometimes 
follow  unwitnessed  uremic  convulsions. 
Dryness  and  uremia  of  the  skin  form  a 
constant  condition.  Urfemic  manifesta- 
tions may  supervene  at  any  period  in 
the  disease,  appearing  early  in  the  most 
severe  cases,  with  intense  headache  and 
backache,  vomiting,  and  convulsions. 

The  above  may  be  considered  a  de- 
scription of  the  common  form  of  acute 
nephritis  resulting  from  exposure;  the 
clinical  course  differs  somewhat  in  other 
cases.  Occurring  as  a  complication  of 
the  infectious  fevers,  except  scarlatina, 
acute  nephritis  may  be  characterized  by 
the  very  slight  degree,  or  even  by  the 
absence,  of  dropsy.    Albuminuria,  ham- 


588 


BRIGHT'S  DISEASE.     ACUTE  NEPHRITIS.     ETIOLOGY. 


aturia,  anemia,  and  urfemia  mark  the 
graver  affections.  In  scarlatinal  nephri- 
tis, however,  anasarca  is  common,  and 
a  slight  oedema,  at  least,  is  quite  con- 
stant. Mild  affections  show  simply  a 
slight  quantity  of  albumin  and  a  few 
hyaline  casts,  indicative  of  the  paren- 
chymatous degeneration.  The  typhoid 
state  may  follow  the  subsidence  of  the 
acute  toxic  symptoms  in  cases  of  degen- 
erative nephritis  due  to  mineral  poison- 
ing; this  is  marked  by  prostration,  mus- 
cular twitchings,  stupor,  coma,  and 
death.  Hasmaturia  may  be  pronounced 
in  the  so-called  nephro-typhoid  condi- 
tion, in  which  typhoid  fever  begins  with 
marked  symptoms  of  acute  nephritis. 
The  nephritis  of  pregnancy,  as  a  rule, 
is  gradual  in  its  onset.  The  albumin 
increases  in  quantity  from  month  to 
month,  reaching  a  high  percentage  dur- 
ing the  eighth  and  ninth.  Some  hyaline 
casts  are  found;  but  otherwise  there  are 
few  morphological  elements.  Red  blood- 
corpuscles  rarely  may  be  seen  in  the 
urine.  Up  to  the  time  of  delivery  the 
danger  of  eclampsia  is  constant,  but  re- 
covery is  rapid  in  uncomplicated  cases 
after  the  birth  of  the  child. 

In  acute  (productive)  nephritis,  where 
there  is  a  tendency  to  the  formation  of 
patches  or  wedges  of  fibrous  tissue,  there 
is  a  higher  fever,  there  are  cerebral  and 
circulatory  disturbances  of  a  typhoid 
nature,  as  well  as  ansemia,  dropsy,  and  a 
highly  albuminous  urine,  even  though 
there  be  no  blood-corpuscles  and  few 
casts.  Dropsy  is  most  marked  in  the 
legs.  There  are  a  progressive  and  rapid 
loss  of  flesh  and  strength,  dyspnoea, 
vomiting,  diarrhoea,  and  convulsions  or 
coma  and  end  in  death.  Milder  cases 
last  from  two  to  four  weeks,  and  appar- 
ently recover;  albumin  and  casts  per- 
sist, however,  until  another  and  a  simi- 
lar  attack   occurs   after   an   interval   of 


weeks  or  months.  Thus,  the  first  acute 
attack  is  subject  to  chronic  recurrence, 
until  a  fatal  seizure  takes  place. 

Etiology. — Acvite  nephritis  more  often 
appears  before  than  after  the  middle 
time  of  life,  though  it  may  occur  at  any 
time.  Males  are  more  often  attacked 
than  females. 

Analysis  of  270  cases  of  Bright's  dis- 
ease. Nephritis  occurred  more  frequently 
in  males  than  in  females  (3.309  to  2.74)  j 
most  common  during  the  period  of  great- 
est activity  of  the  body.  Of  the  270 
eases,  140  were  acute,  85  being  htemor- 
rhagic.  Of  these  140  cases  of  acute 
Bright's  disease,  70  per  cent,  could  be 
traced  to  acute  infectious  diseases,  only 
2.85  per  cent,  being  directly  traceable  to 
cold.  Agnes  Bluhm  (Deutsches  Archiv 
f.  klin.  Med.,  B.  17,  H.  3,  4) . 

Of  251  cases  of  chronic  nephritis  ob- 
served by  Heubner  in  Leipzig,  214 
occurred  in  adults  and  37  in  children. 
He  subsequently  saw  28  cases  in  children 
in  Berlin,  mostly  after  scarlet  fever. 
Of  these  65  cases,  there  were  3  of  paren- 
chymatous nephritis,  4  of  contracted 
kidney,  and  5  of  chronic  hsemorrhagie 
nephritis.  Brill  and  Libman  (Jour,  of 
Exper.  Med.,  Sept.  and  Nov.,  '99). 

Occupations  necessitating  exposure  to 
cold  and  wet  offer  special  predisposing 
conditions.  The  long-continued  use  of 
alcohol  will  also,  as  a  rule,  prove  a  pre- 
disposing cause  of  acute  Bright's  disease. 

Among  the  exciting  causes  of  acute 
diffuse  nephritis  are: — ■ 

1.  Those  acting  on  the  skin,  as  cold, 
dampness,  extensive  burns,  and  chronic 
skin  diseases.  It  is  often  difficult  to 
determine  the  relative  influence  of  alco- 
holic excesses  and  the  exposure  incident 
thereto.  Acute  intoxication  from  beer- 
drinking  may  result  in  an  acute  nephri- 
tis, but  it  is  yet  likely  that  in  most  cases 
the  exciting  cause  is  the  cold  acting 
upon  the  individual  in  his  exposed  and 
maudlin  condition.  Acute  nephritis 
may  also  be  caused,  at  times,  by  exposure 


HEIGHT'S  DISEASE.     ACUTE  NEPHRITIS.     ETIOLOGY. 


589 


to  cold  and  wet  apart  from  and  in  the 
absence  of  alcoholic  indulgence;  in  such 
cases  it  is  to  be  presumed  that  there  is 
an  inherent  weakness  of  the  kidneys,  or 
a  susceptibility  rendering  these  organs 
the  vulnerable  point  in  the  system. 

The  physiological  toxic  agents  embrace 
the  poisons  of  the  acute  infections;  in  a 
majority  of  cases,  however,  scarlet  fever 
is  the  primary  affection.  Usually  the 
nephritis  appears  during  the  second  or 
third  week  of  convalescence,  though  it 
may  supervene  at  the  height  of  the  dis- 
ease. 

Among  97  cases  of  scarlet  fever,  but  4 
exhibited  the  symptoms  of  Bright's  dis- 
ease. Of  45  cases  of  measles  but  1 
evinced  renal  involvement.  In  162  cases 
of  erysipelas,  Bright's  disease  occurred  7 
times  and  simple  albuminuria  17  times. 
Among  481  cases  of  variola  it  appeared 
but  once:  in  a  child  12  months  old.  In 
93  cases  of  diphtheria  it  occurred  but 
4  times  and  simple  albuminuria  but  6 
times.  Of  74  cases  of  tonsillar  angina, 
4  eases  presented  evidence  of  nephritis 
and  20  were  albuminuric.  Among  10 
cases  of  ulcerative  endocarditis  it  oc- 
curred once.  Out  of  360  cases  of  acute 
rheumatism,  but  4  were  affected  second- 
arily by  acute  Bright's  disease.  Acute 
nephritis  is  not  rare  in  acute  pneumonia, 
occurring  in  26  out  of  140  cases.  Agnes 
Bluhm  (Deutsche  Archiv  f.  klin.  Med., 
B.  17,  H.  3,  4). 

Very  grave  nephritis  supervening  in 
the  first  seven  days  of  scarlet  fever,  thus 
differing  from  the  late  nephritis;  to  it 
must  be  ascribed  the  fatal  termination 
sometimes  noticed  in  the  early  stage  of 
scarlet  fever.  Inflammation  extending 
to  the  papilla  constitutes  the  most  essen- 
tial characteristic;  leads  to  retention  of 
urine  and  dilatation  of  the  eanaliculi. 
Aufrecht  (Rev.  des  Sci.  Med.  en  France 
et  a  I'Etranger,  July   15,   '94) . 

Renal  disease  is  associated  with  in- 
sanity in  two  ways:  (1)  acute  transient 
delirious  mania,  an  acute  toxsemia,  or 
ursemic  insanity,  and  (2)  a  progi'essive 
cerebral  degeneration,  with  chronic 
renal  disea.^e  as  the  primary  cause.     In 


this  type  the  mental  symptoms  during 
the  earlier  stages  vary  from  a  mild 
dementia  to  mania  or  delirium.  In  due 
course,  however,  complete  dementia  re- 
sults not  unlike  paralysis  of  the  pro- 
gressive type  known  as  general  paralysis 
of  the  insane. 

In  some  cases  the  spinal  symptoms 
become  marked,  and  changes  in  the 
spinal  cord  are  found  after  death. 

The  dyspnoeic  and  gastrointestinal 
forms  of  uraemia  are  sometimes  seen  in 
the  insane,  but  it  is  with  the  comatose 
and  convulsive  types  that  asylum  phy- 
sicians have  chiefly  to  do. 

Out  of  3000  cases  admitted  to  Beth- 
lem  since  the  year  1SS8,  172  had  albumi- 
nuria on  admission  (or  5.7  per  cent.) ; 
of  these  172,  as  many  as  40  (or  23  per 
cent.)  recovered  from  the  mental  at- 
tack; of  the  remaining  132,  37  died  of 
general  paralysis  and  20  of  senile  de- 
mentia, and  the  remaining  75  became 
incurables.  On  careful  analysis  of  the 
details  of  these  172  cases  is  to  be  noted 
the  comparative  frequency  of  such 
symptoms  as  inequalities  of  the  pupils, 
tongue  tremors,  alterations  and  defects 
of  speech,  sluggishness  or  exaggeration 
of  the  knee-jerks,  and  not  infrequently 
hemiplegias,  or  other  symptoms  of  ar- 
terial and  cerebral  degeneration.  The 
cases  diagnosed  as  general  paralysis  ap- 
peared to  have  been  of  three  types:  (1) 
parasyphilitic  types,  which  correspond 
most  closely  to  the  classical  descriptions 
of  general  paralysis;  (2)  types  of  cere- 
bral degeneration  due  mainly  to  vas- 
cular changes  consequent  upon  kidney 
disease;  and  (3)  types  of  associated 
mental  and  motor  defects  in  which  the 
kidney  disease  is  merely  coincidental, 
the  mental  and  motor  symptoms  being 
due  to  other  factors,  such  as  sunstroke, 
malaria,  post-febrile  and  toxic  states. 
T.  B.  Hyslop  (Practitioner,  Nov.,  1901). 

2.  Acute  nephritis  may  also  be  the 
result  of  other  of  the  infectious  fevers 
(small-pox,  typhus,  typhoid,  relapsing 
fever,  cholera,  diphtheria,  yellow  fever, 
measles,  chicken-pox,  erysipelas,  septico- 
pyemia, acute  lobar  pneumonia,  cerebro- 
spinal meningitis,   dysentery,   acute   ar- 


590 


BRIGHT'S  DISEASE.    ACUTE  NEPHRITIS.     ETIOLOGY. 


ticular  rheumatism,  and  tuberculosis; 
syphilis  is  rarely  a  cause). 

Interesting  case  of  haemorrhagic  ne- 
phritis consecutive  to  grippe,  in  a  woman 
32  years  of  age,  the  haematuria  lasting 
three  weeks.  Bock  (Deutsche  med.-Zeit., 
Apr.  2,  '94). 

Case  in  which  mortal  nephritis  fol- 
lowed mumps.  Le  Boy  (La  France  Med. 
et  Paris  Med.,  Nov.  23,  '94). 

Occurrence  of  nephritis  in  secondary 
syphilis  in  a  case  investigated  in  Birch- 
Hirsehfeld's  laboratory.  The  patient 
died  in  coma.  At  autopsy  the  lungs, 
spleen,  liver,  lymphatic  glands,  and  kid- 
neys were  all  found  to  be  the  seat  of 
more  or  less  interstitial  inflammation. 
The  kidneys  were  large,  and  on  section 
showed  signs  of  subacute  interstitial 
nephritis;  the  epithelium  of  the  tubules, 
which  were  much  compressed,  was  only 
slightly  affected.  These  changes  believed 
to  have  been  due  to  syphilis.  The  ne- 
phritis could  not  have  been  of  mercurial 
origin,  for  it  would  have  been  parenchy- 
matous, and  not  interstitial.  Doederlein 
(Miinchener  med.  Woeh.,  Oct.  13,  '96). 

Acute  interstitial  nephritis  found  in 
42  cases  of  infectious  diseases,  most  fre- 
quently in  diphtheria  and  scarlet  fever. 
The  interstitial  tissue  in  these  cases  is 
infiltrated  diffusely  and  in  feci  by  cells 
resembling  the  plasma-cells  of  Unna. 
No  satisfactory  explanation  can  be  given 
for  the  almost  constant  tendency  of  the 
infiltrating  cells  to  collect,  especially  in 
the  boundary  zone  of  the  pyramids,  the 
subcapsular  region  of  the  cortex,  and 
around  the  glomeruli.  W.  T.  Council- 
man (Jour,  of  Exper.  Med.,  July  and 
Sept.,  '98). 

It  may  also  supervene  as  a  primary 
condition,  and  the  brunt  of  the  attack 
may  be  sustained  either  by  the  kidney, 
rather  than  by  any  other  part,  or  by  the 
organism  as  a  whole,  as  in  the  fevers. 
Mannaberg  has  described  such  cases,  and 
has  demonstrated  the  presence  of  strep- 
tococci in  the  urine. 

Relation  of  acute  nephritis  and  the 
streptococci  found  in  endocarditis,  espe- 
cially  those   of   experimentally    induced 


bacterial  endocarditis.  In  eleven  cases 
of  acute  Bright's  disease  the  urine  found 
to  invariably  contain  streptococci,  which 
disappeared  from  the  excretion  with  the 
disappearance  of  the  symptoms  of  dis- 
ease. In  patients  affected  by  other 
maladies,  and  in  healthy  individuals, 
this  micro-organism  was  not  found,  al- 
though searched  for  in  a  long  series  of 
samples  of  urine.  Mannaberg  (Zeit.  f. 
klin.  Med.,  B.  18,  H.  3,  4). 

A  number  of  cases  of  renal  inflamma- 
tion due  to  a  characteristic  bacillus, 
from  cultures  of  which  he  has  been  able 
to  reproduce  the  nephritis  in  rabbits. 
The  symptoms  are  in  general  similar  to 
those  in  other  cases  of  nephritis,  but  usu- 
ally are  of  a  mild  fonn,  and  are  apt 
to  show  a  predominance  of  the  gastric 
phenomena.  Letxerich  (Zeit.  f.  klin. 
Med.,  B.  18,  H.  5,  6). 

Renal  inflammation  characterized  by 
the  presence  of  micro-organisms,  which 
present  themselves  as  rods  and  spores 
(cocci),  the  former  three  micromilli- 
metres  in  length,  sometimes  bearing  a 
sporangium.  Hopkins  (Pacific  Med. 
Jour.,   Apr.,    '90). 

The  tendency  even  now  is  to  attribute 
too  large  a  share  to  cold  in  the  causa- 
tion of  nephritis.  Taking  the  infective 
diseases  alone,  the  alterations  brought 
about  by  the  micro-organisms  in  the 
renal  tissue  may  pass  without  leaving 
any  trace,  but  they  may  also  become 
chronic,  causing  changes  in  the  epithe- 
lial elements  and  interstitial  prolifera- 
tion. M.  Vignerot  (Arch.  Gen.  de  Med., 
Oct.,  '91). 

Bright's  disease,  an  infectious  disorder 
in  which  the  micro-organisms  act  upon 
the  kidneys.  (1)  Hyperacute  infectious 
Bright's  disease;  (2)  acute  infectious 
Bright's  disease;  and  (3)  attenuated  in- 
fectious Bright's  disease.  Fiessinger  (La 
Sem.  Med.,  May  12, '94). 

Case  of  primary  acute  hsemorrhagic 
nephritis,  in  a  man  42  years  of  age,  co- 
existent with  the  presence  in  the  urine  of 
large  quantities  of  the  staphylococcus 
pyogenes  albus.  Baduel  (Riforma  Med., 
Aug.  7,  '94). 

Seventy  eases  showing  causal  relation- 
ship between  ulceration  of  the  duodenum 
and    interstitial    or    tubal    nephritis,    or 


BRIGHT'S  DISEASE.     ACUTE  NEPHRITIS.     PATHOLOGY. 


591 


both  combined.  Perry  and  Shaw  (Prac- 
titioner, Dec,  '94). 

Case  in  which  nephritis  was  due  to 
infection  through  skin  wound.  Sacaze 
(Eevue'de  M6d.,  Feb.,  '95). 

Case  in  which  ulcer  appeared  as  first 
symptom  in  case  following  a  rapid 
course,  showing  at  autopsy  degeneration 
of  convoluted  tubules  with  slight  ar- 
teritis. Etienne  (Le  Bull.  Med.,  July  14, 
'95). 

When  toxic  substance  reaches  kidney 
through  nutritive  artery  it  exerts  an 
elective  action  upon  the  epithelial  cells 
of  convoluted  tubules,  with  lesions  of 
protoplasm,  steatosis,  and  coagulation 
necrosis.  Vandervelde  (Jour,  de  M6d., 
de  Chir.,  et  de  Pharm.,  vol.  iv.  No.  2, 
'95). 

Case  showing  that  absorption  of  ali- 
mentary ptomaines  which  kidneys  can- 
not eliminate  may  give  rise  to  lethal 
poisoning.     Dieulafoy  (Annual,  '96). 

Three  cases  of  hemorrhagic  nephritis 
caused  by  infection  of  the  blood  with 
bacteria  which  otherwise  did  not  pro- 
duce evident  symptoms.  In  the  first 
case  a  general  infection  of  the  blood,  the 
liver,  the  kidneys,  and  the  spleen  with 
streptococci  was  found  at  the  autopsy; 
the  disease  had  continued  for  eight 
months  and  presented,  as  its  only  symp- 
tom, hsemorrhagic  nephritis;  there  was 
no  fever  except  during  the  last  two 
weeks  of  life.  In  the  second  ease  symp- 
toms of  endocarditis  and  of  haemorrhagic 
nephritis  were  combined;  the  blood  con- 
tained intra  vitam  staphylococcus  albus, 
and  the  same  bacterium  was  found  on 
the  growths  on  the  mitral  valve.  In  the 
third  case  the  examination  of  the  urine 
revealed  the  presence  of  staphylococcus 
albus  in  great  quantity.  The  author  in- 
sists on  the  fact  that  a  general  infection 
of  the  organism  with  bacteria  of  differ- 
ent species  may  reveal  itself  only  by  the 
presence  of  hsemorrhagic  nephritis,  and 
he  believes  that  the  haemorrhages  which 
occasionally  occur  during  the  course  of 
an  ordinary  nephritis  may  be  caused  by 
a  temporary  invasion  of  bacteria  in  the 
blood.  Hoist  (Norsk  Mag.  f.  Laege- 
vidensk.,  p.  825,  '99).  Report  of  Corr. 
Ed.  F.  Levtson. 


3.  Chemical  toxic  agents  include  tur- 
pentine, cantharides,  carbolic  and  sali- 
cylic acids,  potassium  chlorate,  iodoform, 
the  mineral  acids,  and  inorganic  poisons, 
such  as  phosphorus,  arsenic,  mercury, 
and  lead.  Acute  renal  inflammation 
may  be  caused  by  the  excessive  ingestion 
of  highly-acid,  spiced,  or  adulterated 
foods  (as  from  salicylic  acid  and  lead 
chromate). 

Large  number  of  substances — canthar- 
ides,  styrax,  balsam  of  Peru,  cubeb,  tui- 
pentine,  mustard-  and  crotou-  oils,  naph- 
thol,  carbolic  and  oxalic  acids,  phos- 
phorus, etc. — which  act  upon  the  kidney 
as  poisons  by  causing  acute  diffuse 
nephritis.  Lenzmann  (Deutsche  med.- 
Zeit.,  Aug.  6,  '94) . 

Two  cases  of  acute  nephritis,  in  chil- 
dren 8  and  6  years  of  age,  after  the  use 
of  betanaphthol  ointment  for  the  pur- 
pose of  curing  the  itch.  The  youngest, 
child  died.  Baatz  (Centralb.  f.  klin. 
Med.,  Sept.  15,  '94). 

Experiments  with  various  toxics,  and 
clinical  facts  show  that  the  pathological 
process  is  a  uniform  one,  the  epithelium 
of  the  convoluted  tubules,  the  epithelial 
cells  of  the  straight  tubules,  the  glome- 
ruli, the  interstitial  tissue,  and  vascular 
walls  being,  in  turn,  involved.  Bur- 
meister  (Virehow's  Archiv,  B.  137,  H.  3). 

4.  Pregnancy  may  act  as  a  cause  of 
acute  nephritis  (gravidarum).  In  such 
cases  it  usually  appears  in  primipars,  in 
the  last  months  of  gestation,  and  is  prob- 
ably the  result  of  renal  engorgement 
due  both  to  mechanical  pressure  and 
to  nutritive  disturbances  in  the  kidney, 
owing  to  the  altered  blood-condition. 

5.  Latent  chronic  nephritis  may  form 
the  cause  of  a  manifest  acute  nephritis. 

Pathology. — There  is  a  considerable 
variation  in  the  anatomical  changes  in 
and  the  appearance  of  the  kidneys,  ac- 
cording to  the  degree  of  involvement. 
Between  the  very  mild  and  grave  cases 
there  is  an  intermediate  series  of  con- 
tinuously    more     marked     pathological 


592 


BRIGHT'S  DISEASE.    ACUTE  NEPHRITIS.    PATHOLOGY. 


changes  dependent  upon  the  amount  of 
poisonous  material  circulating  in  and 
eliminated  by  the  kidneys,  as  well  as 
upon  the  intensity  and  duration  of  its 
toxic  action. 

There  may  be  no  microscopical  change 
in  the  mildest  cases.  As  a  rule,  how- 
ever, the  kidneys  are  slightly  enlarged, 
swelled,  and  somewhat  softened,  though 
these  conditions  are  more  evident  when 
the  interstitial  exudation  is  abundant 
and  inflammatory  oedema  is  evident.  On 
section  the  organs  may  appear  red  and 
congested  or  they  may  be  pale  and 
mottled.  In  the  former  case  hffimor- 
rhages  may  appear  beneath  the  capsule 
(acute  hsemorrhagic  nephritis);  it  is 
more  usual,  however,  to  see  red,  hyper- 
semic  patches  alternating  with  opaque 
and  whitish  portions,  both  on  the  outer 
and  the  cut  siirfaces.  Especially  is  the 
cortex  swelled,  turbid,  and  pale,  or 
slightly  congested  in  the  mildest  cases; 
in  severe  attacks  it  is  deeply  mottled 
(red  and  pale  glomeruli)  or  hypersemie. 
The  surfaces  are  smooth  and  the  capsule 
non-adherent.  The  pyramids  usually 
show  an  intense-red  color. 

In  the  very  mild  cases,  already  referred 
to,  changes  may  be  noted  microscopic- 
ally that  are  not  visible  to  the  naked 
eye,  there  being  simply  a  cloudy  swelling 
or  a  granular  (parenchymatous)  degen- 
eration of  the  epithelium  of  the  Mal- 
pighian  tufts.  Bowman's  capsule,  and  of 
the  uriniferous  tubules  of  the  cortex. 
In  the  absence  of  exudative  changes  in 
the  interstitial  tissue,  however,  this  can- 
not be  called  true  acute  nephritis.  The 
acute  parenchymatous  degeneration  may 
be  limited  almost  exclusively  to  the 
glomeruli,  as  in  some  cases  of  scarlatina, 
and  from  this  fact  has  arisen  the  term 
"glomerulonephritis."  The  muscles  are 
either  swollen  or  absent;  the  cells  are 
swollen,  opaque,  and  irregular  in  shape; 


and  the  cell-contents  are  granular  (albu- 
minoid or  fatty).  The  death  of  the 
cells — owing  to  coagulation  necrosis  or 
disintegration,  desquamation",  and  hya- 
line degeneration  of  masses  of  the  cells 
in  the  tubules — marks  a  further  stage  in 
the  process.  Acute  degenerative  changes 
are  frequently  found  in  the  acute  infec- 
tious diseases,  or  when  inorganic  poisons 
have  been  introduced  into  the  body.  In 
phosphoric  poisoning  there  may  be  an 
actual  fatty  degeneration  of  the  epithe- 
lium, either  proceeding  from  the  cloudy 
swelling  or  occurring  as  an  independent 
development.  In  severe  cases  a  rapid 
necrosis  of  the  cells  is  also  met  with. 

True  acute  nephritis  exhibits  not  only 
changes  in  the  parenchyma  (epithelium), 
but  also  an  inflammatory  exudate  be- 
tween the  tubules,  consisting  of  serum, 
leucocytes,  and  red  blood-corpuscles.  In 
some  places  the  kidneys  show  only  a 
slight  cellular  infiltration  of  the  inter- 
tubular  tissues.  In  others  the  intersti- 
tial tissue  is  swelled  by  the  coagulated 
serofibrinous  exudate,  many  leucocytes, 
and  some  erythrocytes,  besides  the  des- 
quamation of  necrotic  epithelial  cells 
and  the  presence  of  hyaline  casts  in  the 
tubules.  The  inflammatory  exudate  col- 
lects, also,  in  the  Malpighian  bodies  and 
tubules.  The  tubules  may  be  dilated 
and  choked  with  degenerated  cells,  or 
more  frequently  the  straight  tubules  are 
clogged  with  hyaline  easts.  The  lining 
epithelium,  especially  in  the  convoluted 
portion  of  the  tiibules,  is  often  flattened. 
The  white  blood-corpuscles  infiltrating 
the  stroma 'of  the  kidneys  are  collected 
in  foci  in  the  cortex,  and  not,  as  a  rule, 
equally  diffiTsed. 

The  outlines  of  the  individual  capil- 
laries are  lost,  and  the  glomerular  epi- 
thelium of  the  capsule — especially  that 
covering  the  inside  of  the  capillaries  of 
the  tufts — is  swelled  and  opaque.    New 


BRIGHT'S  DISEASE.    ACUTE  NEPHRITIS.    DIAGNOSIS. 


593 


epithelium  appears  in  most  instances  of 
diffuse  exudative  nephritis,  and  a  res- 
toration of  the  glomerular  function  oc- 
curs. According  to  Delafield,  in  the 
productive  variety  of  acute  diffuse  ne- 
phritis, however,  certain  lesions  are  more 
permanent  in  character  from  the  outset 
in  the  glomeruli  and  stroma,  and  hence 
the  increased  gravity  of  the  disease. 
Superadded  to  the  usual  exudative  con- 
dition are  the  following  changes:  (a)  a 
growth  of  the  cells  lining  the  capsules, 
such  as  to  form  a  mass  that  compresses 
the  tuft,  "and  leading,  finally,  to  obliter- 
ation of  the  vessels  and  fibroid  glome- 
ruli"; (&)  a  growth  of  the  connective 
tissue  parallel  to,  and  surrounding,  one 
or  more  arteries  having  thickened  walls, 
and  forming  more  or  less  numerous  and 
regular  strips  or  wedges  in  the  cortex. 
The  new  tissue  between  the  tubules  is, 
in  the  more  intensely  acute  cases,  largely 
cellular;  in  those  of  a  subacute  type  it  is 
relatively  dense  and  fibrous. 

Pleural,  pericardial,  and  peritoneal 
dropsy,  as  well  as  anasarca,  are  also 
found  in  those  dying  of  acute  Bright's 
disease.  Meningitis,  cerebral  oedema, 
and  lobar  pneumonia  are  also  sometimes 
seen  post-mortem. 

Diagnosis.  —  Acute  Bright's  disease 
can  hardly  be  overlooked  when  the 
urine  is  carefully  examined  chemically 
and  microscopically.  The  eclampsia  of 
pregnancy  can,  however,  be  recognized 
only  by  repeated  examination  of  the 
urine,  especially  during  the  last  months 
of  pregnancy. 

Case  of  subacute  nephritis  subsequent 
to  an  attack  of  simple  herpetic  tonsillitis. 
On  the  fifteenth  day  an  eclamptic  crisis 
suddenly  set  in,  accompanied  with 
anuria.  Urine  contained  1 '/,  drachms  of 
albumin  per  quart.  The  crisis  became 
more  frequent,  coma  set  in,  and  the 
patient  died  with  broncho-pneumonia. 
Histological  examination  of  the  kidneys 

1- 


showed,  on  the  tubular  epithelia,  an  im- 
mediate lesion  with  cloudy  tumefaction 
and  coagulation  necrosis.  Siraud  (Revue 
Inter,  de  Bibliographic,  Apr.  25,  '94). 

Three  cases  of  acute  interstitial  ne- 
phritis. The  first  was  a  case  of  general 
streptococcic  infection  after  abortion; 
the  second  also  followed  abortion,  but 
the  kidneys  were  sterile;  the  third  was 
due  to  streptococcic  infection  and  oc- 
curred with  broncho-pneumonia  second- 
ary to  otitis  media.  Councilman  in  1898 
reported  42  cases,  in  which  he  found 
Unna's  plasma-cells  to  be  the  most 
numerous  cells  of  the  renal  exudate, 
lymphocytes  and  polynuclear  leucocytes 
being  also  present  in  variable  numbers. 
In  the  three  cases  plasma-cells  and 
lymphocytes  were  present,  but  in  each 
case  there  was,  in  addition,  the  eosino- 
philic leucocyte,  a  cell  not  hitherto  de- 
scribed in  nephritic  exudations.  W.  T. 
Howard,  Jr.  (Amer.  Jour.  Med.  Sci., 
Feb.,  1901). 

Acute  Bright's  disease  should  be  sus- 
pected, and  the  urine  examined,  in  every 
case  showing  pallor  of  the  skin  and  puffy 
eyelids,  whether  general  prostration  of 
the  health  is  apparent  or  not.  The  char- 
acteristic symptoms  of  acute  exudative 
nephritis,  as  commonly  seen  when  the 
condition  is  due  to  cold  or  occurs  in 
scarlet  fever,  are  the  following:  Head- 
ache, restlessness,  muscular  twitching, 
nausea  and  vomiting,  a  tense  pulse, 
moderate  fever,  dropsy,  and  anaemia. 
Tube-casts  and  albuminuria  are  constant. 
It  should  be  borne  in  mind  that  slight 
albuminuria  occurring  in  the  course  of 
pregnancy  or  during  any  of  the  fevers, 
without  casts,  is  not  a  true  nephritis, 
although  the  latter  may  be  a  more  or  less 
remote  consequence  of  the  glandular  de- 
generation of  the  renal  epithelium  asso- 
ciated with  the  febrile  albuminuria.  In 
addition  to  the  presence  of  albumin  and 
hyaline  and  cell-  casts,  however,  a  di- 
minished quantity  of  sooty-looking  urine 
and  the  discovery  of  red  and  white 
38 


594 


BRIGHT'S  DISEASE.    ACUTE  NEPHRITIS.    PROGNOSIS.    TREATMENT. 


blood-corpuscles  will  render  the  diagno- 
sis positive.  The  history  of  the  case  and 
the  causal  factors  are  also  to  be  taken 
into  consideration. 

Prognosis.  —  A  case  of  ordinary  exu- 
dative nephritis  following  exposure  to 
cold  and  wet  runs  a  course  varying  from 
a  few  days  to  three  or  more  weeks. 
There  is  a  steady  diminution  of  the 
albuminuria,  which  finally  disappears 
together  with  the  casts,  while  the  daily 
quantity  of  lighter  urine  and  the  daily 
excretion  of  urea  increase.  The  char- 
acter and  intensity  of  the  renal  inflam- 
mation, and  the  primary  disease  or  caus- 
ative conditions  largely  determine  the 
prognosis.  Scarlatinal  nephritis  gives 
much  less  hope  of  recovery  than  does 
nephritis  due  to  exposure  to  cold  after 
alcoholic  excesses.  Recovery  usually 
takes  place  easily  after  the  acute  paren- 
chymatous degeneration  that  accom- 
panies diphtheria,  typhoid,  and  other 
infectious  fevers,  as  well  as  pregnancy. 
In  acute  yellow  atrophy,  however,  and 
in  yellow  fever,  cholera,  severe  phos- 
phoric or  mercurial  poisoning,  death 
may  occur  from  the  intense  and  wide- 
spread necrosis  of  renal  epithelium.  The 
dropsy  and  albuminuria  gradually  dimin- 
ish in  favorable  cases  of  ordinary  exu- 
dative nephritis,  while  the  color  of  the 
skin  and  the  quantity  of  urine  and  urea 
increase;  so  that  recovery  is  established 
in  from  three  to  six  weeks.  The  albu- 
min may  persist  for  some  time  after  the 
disappearance  of  the  dropsy,  and  then 
gradually  disappear;  rarely,  however,  in 
unfavorable  eases,  albuminuria  may  con- 
tinue and  the  affection  become  chronic 
parenchymatous  nephritis,  even  after  the 
dropsy  has  disappeared. 

Acute  nephritis  presents  a  number  of 
serious  and  often  dangerous  symptoms. 
Among  these  are  severe  general  oedema, 
dropsical  effusions  into  the  serous  sacs 


(as  hydrothorax),  ursemia  (especially 
when  beginning  with  cerebral  manifes- 
tations, as  convulsions  or  coma),  and, 
finally,  inflammation  of  the  internal 
organs,  as  pneumonitis,  pleuritis,  peri- 
carditis, peritonitis,  and  meningitis. 
Eecovery  is  quite  common  in  cases  of 
marked  general  dropsy  in  the  absence 
of  ureemia.  Suppression  of  the  urine, 
however,  if  it  last  more  than  twenty-four 
or  forty-eight  hours,  is  usually  a  fatal 
symptom.  In  those  cases,  also,  in  which 
the  nephritis  has  a  productive  character, 
the  prognosis  is  unfavorable,  though  life 
may,  in  some  cases,  be  prolonged  for 
several  years. 

Case  of  acute  Bright's  disease  ending 
fatally  in  seventeen  days  in  a  child,  3 
months  old,  and  not  consequent  upon  a 
skin  affection  or  scarlatina.  T.  B.  Green- 
ley  (Amer.  Pract.  and  News,  June  15, 
'98). 

Treatment.  —  The  first  object  in  the 
treatment  is  to  relieve  the  congestion 
and  inflammation,  since  the  renal  func- 
tion is  diminished  by  these  conditions; 
by  these  means  we  restore  the  excretory 
function.  It  is,  therefore,  in  order  ta 
restore  the  functional  equilibrium  by 
their  antiphlogistic  influence,  that  the 
single  or  combined  use  of  diaphoretics 
and  cathartics  is  employed,  and  not  that 
the  skin  and  bowels  shotild  be  made  to 
perform  the  work  normally  done  by  the 
kidneys. 

Absolute  rest  in  a  warm  bed  and  in 
a  warm  room  is  of  primary  importance, 
and,  in  order  to  promote  a  constant  and 
free  action  of  the  sweat-glands,  woolen 
underwear  and  blankets  should  be  used. 
These  measures  are  of  importance  both 
in  mild  and  severe  cases. 

The  diet  should  consist  of  bland 
liquid  foods  only,  and  the  patient  should 
be  urged  to  drink  freely  of  water  (plain, 
distilled,     or     carbonated),     lemonade,. 


BRIGHT'S  DISEASE.     ACUTE  XEPHRITIS.     TREATSIEXT. 


595 


skimmed  milk,  or  buttermilk,  all  of 
which  are  of  especial  value  when  hot. 
Thin  meat-broths  may  be  allowed  later 
in  the  course  of  the  disease,  although  a 
strict  milk  diet  is  preferable. 

In  rare  eases  in  which  there  is  severe 
pain,  local  blood-letting,  by  means  of 
leeches  or  cupping  over  the  loins,  may 
be  useful;  these  measures  are  seldom 
needed,  however,  and  a  more  salutary 
effect  may  often  be  gained  by  hot  fomen- 
tations. Diminution  of  the  oedema  and 
the  elimination  of  urea  and  other  uri- 
nary constituents  retained  in  acute  ne- 
phritis are  best  attained  by  exciting  a 
profuse  perspiration.  The  congestion  of 
the  kidneys  is  also  relieved  by  this 
vicarious  action  of  the  skin.  The  same 
results  may  also  be  accomplished  by 
means  of  the  hot-air  or  hot-water  bath 
and  the  hot  wet  pack;  in  most  cases  the 
last  method  proves  effective.  It  is  easily 
applied  by  wringing  a  blanket  out  of  hot 
water,  wrapping  the  patient  in  it,  and 
surrounding  him,  first  with  a  dry 
blanket  and,  finally,  with  a  rubber  cloth. 
According  to  the  condition,  the  patient 
may  remain  in  this  improvised  steam 
bath  until  free  sweating  has  continued 
for  an  hotir  or  more.  Children  suffering 
from  scarlatinal  nephritis  may  either 
be  treated  thus,  or  by  immersion  in  hot 
water  for  twenty,  thirty,  or  more  min- 
utes; the  child  is  then  wrapped  in  warm 
sheets  or  blankets,  after  lightly  drying 
the  skin,  and  warmly  covered  in  bed. 
Hot  air  or  vapor  may  also  be  generated 
beside  the  bed  and  introduced  beneath 
the  cradled  bed-clothing  by  means  of  a 
tin  funnel  and  pipe.  The  drinking  of 
hot  lemonade  or  soda-water,  or  of  water 
containing  spirit  of  Mindererus,  will 
stimulate  the  sweating.  Should  these 
measures  fail,  as  in  ursemia,  perspiration 
may  be  started  by  an  hypodermic  injec- 
tion of  pilocarpine,  Vs  to  ^/o  grain;    it 


will  then  continue  to  pour  out  upon 
the  application  of  heat.  Serious  conse- 
quences sometimes  attend  the  use  of 
pilocarpine,  and  the  heart  and  pulse 
must  always  be  carefully  watched.  The 
sweating  should  be  repeated  as  often  as 
the  patient's  strength  will  permit,  until 
the  dropsy  disappears. 

The  depression  of  the  heart's  action 
produced  by  pilocarpine  is  very  similar 
to  that  caused  by  nicotine.  The  toxic 
effects  of  the  drug  are  best  overcome  by 
atropine.  'SMiere  toxic  effects  result  from 
the  administration  of  pilocarpine,  the 
ordinai-y  circulatory  stimulants  should 
also  be  resorted  to.  Probably  the  only 
cases  in  which  pilocarpine  could  be  used 
with  safety  are  those  in  which  there  is 
simple  hypertrophy  of  the  heart,  with  a 
strong  action.  The  contractive  power  of 
the  heart  is  what  should  be  depended 
upon  as  a  guide.  Its  employment  is  cer- 
tainly contra-indicated  if  there  is  any 
dullness  over  the  lungs,  or  pneumonia, 
emphysema,  pleurisy,  coma,  fatty  de- 
generation of  the  heart,  or  cardiac  in- 
sufficiency. To  ascertain  the  condition 
of  the  cardiac  muscle,  auscultation  with 
the  binaural  stethoscope  is  called  for, 
and  any  impairment  of  the  first  soxmd  of 
the  heart  should  make  one  hesitate  to 
use  pilocarpine.  C.  J.  Proben  (Med. 
Xews,  Aug.  1,  '96). 

Pilocarpine  liable  to  produce  a  kind  of 
broncliorrhoea  which  is  almost  always 
fatal.  Case  seen  in  consultation  of  a 
child,  2  years  of  age,  who  had  recently 
had  scarlet  fever.  The  attack  was  not  a 
severe  one,  but  it  was  followed  by  kidney 
disease,  which  resulted  in  general  ana- 
sarca. A  single  dose  of  pilocarpine  was 
administered,  and  as  a  result  of  this 
bronchon-hoea  was  rapidly  produced,  ac- 
companied by  the  most  intense  dyspnoea, 
so  that  the  patient  soon  succumbed. 
Other  cases  seen,  however,  in  which  the 
remedy  acted  with  the  most  happy  effect. 
J.  Lewis  Smith  (Med.  Xews,  Aug.  1,  '96). 

While  pilocarpine  is  a  dangerous 
remedy,  which  should  always  be  used 
with  great  discrimination,  bad  effects 
never  personally  observed  from  its  use; 
only  from  '/,;  to  '/,.  grain  administered. 


596 


BRIGHT'S  DISEASE.     ACUTE  NEPHRITIS.     TREATMENT. 


however,  usually  combined  with  some 
cardiac  stimulant,  such  as  strychnine  or 
digitalis.  J.  Blake  White  (Med.  News, 
Aug.  1,  '96). 

External  application  of  pilocarpine  in 
the   dorso-lumbar  region,   employing   an 
ointment  of  3  ounces  of  vaselin  and  from 
%   grain   to    1 V2   grains   of  pilocarpine 
nitrate.    Surface  frequently  covered  with 
a  layer  of  cotton,  which  is  allowed  to 
remain  on  during  the  day.    Out  of  eighty 
cases,  the  acute  were  rapidly  restored  to 
health  and  chronic  cases  were  improved. 
There  was  marked  diaphoresis  and  diu- 
resis and  albumin  often  disappeared  from 
the   urine.     Julia    (Lyon   Med.,   Dec.   6, 
'96). 
Hydragogues,  as  elaterium,  the  saline 
cathartics,  and  compound  jalap  powder, 
are  useful  as  adjuvant  measures.     The 
extract  of  elaterium  (^/e  to  ^/4  grain) 
is  prompt  in  action,  and  magnesium  or 
sodium  sulphate  (1  drachm)  given  in  hot 
concentrated  solution  every  hour,  or  a 
calomel  purge,  may  also  be  recommended. 
In  extreme  cases  of  dropsy  it  may  be 
necessary  to  relieve  the  tension  and  dis- 
tress by  the  use  of  a  small  trocar  and 
cannula,  with  a  drainage-tube  (Southey) 
attached  to  the  latter  after  the  trocar  is 
withdrawn,   or  by   multiple   punctures. 
If  either  hydrothorax,  hydropericardium, 
or  ascites  assumes  serious  features,  as- 
pirations will  become  necessary.    To  the 
diaphoretic  treatment  may  be  added  V2" 
ounce  doses  of  the  spirit  of  Mindererus 
in  water.    This,  combined  with  aconite, 
aids  in  controlling  the  fever  that  may  be 
present  and  in  preventing  the  vasocon- 
striction  that   is   often   premonitory   of 
nrsemic  symptoms. 

If  the  urajmic  convulsions  do  not 
promptly  yield  to  diaphoresis  and  cathar- 
sis, venesection  must  be  resorted  to,  the 
withdrawal  of  as  much  as  a  pint  or  two 
of  blood  often  saving  life.  Occasionally 
inhalations  of  chloroform  are  needed  to 
subdue  the  violent  convulsive  seizures, 
as  in  eclampsia.     Their  recurrence  may 


be  prevented  by  the  use  of  rectal  injec- 
tions of  potassium  bromide  (1  drachm) 
and  chloral  (V2  drachm). 

Contraction  of  the  arteries  with  in- 
creased tension  and  beginning  muscular 
twitchings  require  the  use  of  chloral- 
hydrate,  nitroglycerin,  and,  possibly, 
morphine. 

Nausea  and  vomiting  may  be  held  in 
control  by  minute  doses  of  cocaine, 
cracked  ice,  dilute  hydrocyanic  or  hydro- 
chloric acid,  bismuth,  or  by  the  addition 
of  soda-  or  lime-  water  to  the  milk. 

There  is  little  advantage  in  diuretics 
other  than  the  simple  diluent  drinks 
already  mentioned,  at  least  early  in  the 
course  of  the  disease.  Later,  potassium 
bitartrate  or  acetate,  sodium  benzoate, 
as  adjuvants  to  the  water,  and  stimulants 
to  relieve  cardiac  depression,  or  caffeine 
citrate  and  the  infusion  of  digitalis,  may 
be  given,  well  diluted. 

In  infectious  nephritis  of  young  sub- 
jects, with  or  without  anasarca,  tinct- 
ure of  cantharides  in  doses  of  10  to  12 
drops  is  very  beneficial.  It  is  contra- 
indicated  in  the  interstitial  nephritis  of 
arteriosclerosis  and  in  lead  poisoning. 
Mile.  A.  Myszynska  (These  de  Paris,  No. 
24,  '96). 

Care  must  be  taken  during  convales- 
cence that  the  patient  be  not  exposed  to 
cold.  The  diet  must  not  be  changed  to 
solids  either  too  suddenly  or  too  rapidly, 
and  particularly  does  this  rule  hold  in 
the  matter  of  meats.  Milk  should  form 
the  mainstay  of  the  dietary,  and  light 
watery  vegetables,  fruits,  and  cereals  may 
be  gradually  added.  The  ansemia  will 
indicate  the  ferruginous  tonics. 

The  fatal  result  is  reached  in  many 
cases  only  because  the  rigid  course  of 
management  necessary  to  stem  the  prog- 
ress of  the  disease  is  not  enforced  until 
irreparable  mischief  is  done  to  the  kid- 
neys. The  patient  should  avoid  fatigue, 
mental  wear,  errors  in  diet,  exposure  to 
cold  or  damp,  and  keep  the  skin  thor- 


BRIGHT'S  DISEASE.     ACUTE  NEPHRITIS.     TREATMENT. 


597 


oughly  protected.  The  urine  should  be 
examined  at  stated  periods  (monthly)  to 
ascertain  whether  any  trouble  is  still 
lurking  or  has  been  redeveloped.  Jacob 
Price  (Med.  and  Surg.  Reporter,  Apr.  24, 
'97). 

Not  a  single  e.xact  clinically  expei'i- 
mental  basis  found  in  all  the  literature 
for  the  exclusion  of  dark  meats  in  chronic 
nephritis,  but  only  hypothetical  affirma- 
tions over  the  greater  content  of  irri- 
tating products  (especially  nitrogenous 
extractives)  for  the  kidneys  in  brown 
meat.  In  a  personal  case  a  patient  with 
chronic  parenchymatous  nephritis  who 
took  V2  pound  of  poultry  daily  for  five 
days  excreted  the  same  amount  of  ni- 
trogen and  a  trifle  more  albumin  than  he 
did  in  the  next  five  days,  in  which,  in- 
stead of  the  poultry,  he  took  an  equiva- 
lent amount  of  nitrogen  in  beef. 

In  many  cases  also  a  restriction  of  the 
amount  of  fluids  to  42  or  50  ounces  can 
be  of  great  advantage.  This  treatment 
is  peculiarly  applicable  to  those  cases 
with  cardiac  asthma  and  dilation  of  the 
heart.  Patients  with  interstitial  ne- 
phritis suffer  no  diminution  in  the  elimi- 
nation of  the  important  metabolic  prod- 
ucts by  the  restriction  of  liquids  to  1  'A 
litres.  Von  Noorden  (Verhandl.  d.  Cong, 
f.  innere  M6d.,  p.  386,  '99). 

Indication  for  milk  diet.  The  prevail- 
ing custom  to  put  the  patient  on  a  strict 
or  partial  milk  diet  has  been  strongly 
condemned  by  von  Noorden,  Lancereaux, 
and  others,  the  second  named  holding 
that  it  is  oulj'  advisable  in  desquamative 
nephritis,  and  not  in  the  interstitial 
variety. 

Great  care  should  be  taken  to  deter- 
mine whether  the  albuminuria  is  func- 
tional or  due  to  a  kidney  lesion,  which 
can  only  be  ascertained  by  a  prolonged 
and  careful  investigation  of  the  patient's 
antecedents  and  habits.  If  it  be  con- 
cluded that  there  is  a  chronic  nephritis, 
the  medication  must  assume  a  depurative 
character,  as  no  medicines  are  capable 
of  curing  the  disease.  Milk  is  very  valu- 
able in  such  cases.  In  functional  cases, 
however,  the  cause  may  be  nervous, 
gastro-hepatic,  gouty,  or  due  to  gravel, 
rapid  growth,  or  menstrual  disorder,  and 
here  treatment  should  be  directed  to  the 


cause.  As  a  result  of  neglect,  such 
transient  albuminuria  may  become  per- 
manent, owing  to  chronic  injury  of  the 
renal  epithelium.  In  these  cases  milk 
may  be  largely  used  or  not,  as  may  seem 
best  in  regard  to  the  general  health  and 
nutrition,  and  its  digestibility  in  indi- 
vidual instances.  Marboux  (Lyon  Mfid., 
Feb.  11,  1900). 

Indications  for  milk  diet.  In  cases  of 
functional  albuminuria,  as  in  the  early 
stage  of  gout  or  in  lithiasis,  at  the  time 
of  puberty,  menstrual  or  digestive  albu- 
minuria, an  exclusive  milk  diet  evokes 
no  other  result  than  great  weakness  and 
sometimes  an  intense  degree  of  anaemia, 
without  causing  a  disappearance  of  the 
albumin.  The  same  cases  improved 
under  a  mixed  diet  in  combination  with 
some  Avater  cure.  It  is  necessary  to  de- 
termine the  source  of  the  albuminuria. 
If  a  chronic  nephritis  of  whatever  origin 
is  present,  the  nutrition  of  the  patient 
must  be  the  first  consideration.  Here 
milk  is  at  once  a  medicine  and  a  food. 
If  simple  albuminuria  with  no  renal  ele- 
ments in  the  sediment  is  noted,  if  it  is 
dependent  upon  some  nervous,  gastro- 
hepatic,  or  gouty  factor,  or  if  a  calculus 
is  the  cause,  the  cause  must  be  treated, 
since  the  albumin  may  eventually  have 
a  deleterious  effect  upon  the  epithelium 
of  the  kidney.  In  such  cases  a  mixed 
diet  containing  milk  is  to  be  advised. 
Victor  Scheiber  (Wiener  med.  Blatter, 
Mar.  8  and  15,  1900). 

Patients  with  chronic  nephritis  seem 
to  thrive  best  on  a  mixed  meat  diet, 
neither  the  white  nor  the  dark  meat  of 
fowls  appearing  to  be  injurious.  A. 
Pabst  (Berliner  klin.  Woeh.,  June  18, 
1900). 

Carefully  regulated  habits  in  regard 
to  dress,  exercise,  and  diet,  and  a  change 
to  a  warmer,  drier,  and  more  equable 
climate,  are  necessary  in  cases  that  are 
convalescent  from  the  very  serious  forms 
of  nephritis,  in  which  the  renal  paren- 
chyma, by  the  persistence,  at  intervals, 
of  a  slight  albuminuria,  is  shown  to  have 
been  somewhat  damaged. 

In  acute  nephritis  in  children,  rest  in 
bed  and  strict  milk  diet;     from  one  to 


598 


BRIGHT'S  DISEASE.     ACUTE  NEPHRITIS.     TREATMENT. 


two  scarified  cuppings  on  each  side  of 
the  spine,  with  mustard  plasters;  every 
two  hours  2  Vi  drachms  of  benzonaph- 
thol  and  2  ^/„  drachms  of  milk-sugar  in 
an  effusion  of  cherry-stalk;  morning  and 
evening  cold  boiled-water  enema;  once 
or  twice  a  week  julep  and  scammony; 
dry  friction  of  the  body,  and  asepsis 
of  the  mouth.  Perier  (Jour,  de  Med., 
Apr.  29,  '94). 

When  acute  or  subacute  attack  ap- 
pears, more  or  less  long  sojourn  in  bed, 
patient  lying  between  blankets.  Warm 
climate,  but  not  on  or  near  the  sea. 
Brushing  of  skin,  but  no  baths,  lest 
patient  take  cold.  Moderate  exercise  or 
massage.  Pregnancy  contra-indicated; 
sexual  sobriety  important.  Milk  the 
food  and  medicine  par  excellence;  2 
quarts  daily  need  not  be  exceeded. 
When  marked  improvement,  vegetarian 
diet.  Purgatives  and  diuretics  only 
remedies  needed,  and  caffeine  subcutane- 
ously  if  heart  show  sign  of  failure. 
Sapelier  (Bull.  Gen.  de  Ther.,  Nov.  30, 
'94). 

Hot  baths  and  milk  diet  best  meas- 
ures. Diuretics  useless.  Though  calo- 
mel acts  as  such,  stomatitis  is  difficult 
to  avoid.  Eepenak  (St.  Petersburger 
med.  Woch.,  Apr.,  '95). 

Examination  of  six  thousand  speci- 
mens at  Denver,  a  mile  above  sea-level. 
Influence  of  high  altitude:  Acute  ne- 
phritis, though  uncommon,  is  exception- 
ally severe.  Amyloid  disease  is  less  fre- 
quent than  text-books  infer.  Chronic 
parenchymatous  nephritis  is  not  influ- 
enced. The  chronic  interstitial  type  of 
this  disease  is  influenced  favorably  by 
the  tonic,  invigorating  climate.  Slight, 
transient  albuminuria,  due  to  high 
blood-pressure,  is  frequent.  E.  0.  Hill 
(Jour.  Amer.  Med.  Assoc,  May  12,  1900). 
Puncture  of  the  kidney  has  recently 
been  recommended. 

Puncture  of  the  kidney  to  relieve  ten- 
sion and  cause  cessation  of  albuminuria. 
Exploration  of  the  kidney  had  been 
undertaken  to  discover  if  there  were  a 
co-existing  morbid  condition  present. 
Good  results  followed  and  appeared  in- 
explicable. They  were  thought  to  be  due 
to  such  factors  as  the  division  of  a  nerve, 
the  moral  effects   of  the  operation,  etc. 


After  several  cases  showed  the  same  re- 
sults, a  different  explanation  became 
necessary.  In  three  subsequent  cases, 
one  of  scarlatinal  nephritis,  one  of 
nephritis  from  exposure  to  damp  and 
cold,  and  one  of  nephritis  following  influ- 
enza, the  albumin  disappeared  from  the 
urine  directly  after  surgical  treatment; 
it  was,  therefore,  believed  that  the 
albuminuria  was  due  to  a  state  of  ten- 
sion in  the  kidney,  which  was  relieved 
by  the  operation.  In  a  proportion  of 
cases  of  nephritis  albuminuria  disap- 
pears; in  others  it  is  very  persistent.  It 
is  in  these  that  surgical  exploration  of 
the  kidney  is  indicated.  This  is  particu- 
larly the  case  when  the  kidney  compli- 
cation is  grave  from  the  outset  and  there 
is  more  or  less  suppression  of  the  urine, 
and  when,  after  a  limited  time,  the 
renal  symptoms  do  not  tend  to  disappear. 
The  operation  of  exploration  is  so  safe 
that  it  is  justified  in  all  severe  renal 
disorders.  "The  kidney  should  be  ex- 
posed by  a  moderate  incision  from  the 
loin,  so  as  to  enable  the  operator  to  feel 
the  organ  distinctly  both  in  front  and 
behind,  aided,  of  course,  by  pressure 
exercised  on  the  kidney  by  the  hand  of 
an  assistant  from  the  front  of  the  ab- 
domen. If,  in  conjunction  with  the  pres- 
ence of  albumin  in  the  urine,  the  kidney 
is  found  in  a  state  of  tension,  such  as  I 
have  illustrated,  three  or  four  punctures 
may  be  made  through  the  capsule  in 
various  directions;  or,  should  the  organ 
be  found  in  a  state  of  higher  tension, 
then  a  limited  incision  into  the  cortex 
may  be  practiced.  After  one  or  other 
of  these  measures  has  been  executed, 
the  wound  should  be  lightly  packed 
with  gauze  or  a  drainage-tube  substi- 
tuted. In  either  case  the  incision  should 
be  dressed  in  such  a  manner  as  to  pro- 
vide for  the  free  escape  of  either  blood 
or  urine  or  whatever  products  may 
be  exuded."  Reginald  Harrison  (Med. 
Weekl}',  Oct.,  '96;  Med.  Record,  Nov. 
7,  '96). 

Case  of  a  woman  suffering  from  a 
nephritis  with  profuse  haematuria  and 
alarming  symptoms  of  ursemia  in  which 
the  disease  was  checked  by  a  nephrot- 
omy. Results  given  in  24  instances  of 
intervention  in  nephritis,  complicated  by 


BRIGHT'S  DISEASE.    EXUDATIVE  CHRONIC  NEPHRITIS.    SYMPTOMS. 


599 


grave  symptoms.  In  9  cases  of  nephritis 
with  hsematuria  there  were  7  nephrec- 
tomies with  2  deaths  and  5  recoveries, 

1  nephrectomy  witli  recovery,  I  simple 
exploration  with  recovery.  In  4  eases 
with  subacute  infectious  nephritis  these 
were  submitted  to  nephrectomy  and  all 
recovered.  In  8  cases  of  acute  infectious 
nephritis  there  were  3  nephrectomies 
with  recovery,  and  5  nephrotomies  with 

2  deaths  and  3  recoveries.  As  to  the 
therapeutic  results,  in  the  first  set  the 
hsematuria  disappeared  at  the  same  time 
the  urinary  secretion  and  elimination  of 
urea  were  re-established.  The  pain 
abated  in  the  nephralgias.  The  albumin 
disappeared  in  the  cases  of  subacute  ne- 
phritis, and  the  fever  and  other  symp- 
toms in  the  severe  infectious  cases  also 
disappeared.  Pousson  (Jour.  Cut.  and 
Genito.-Urin.  Dis.;  Ther.  Gaz.,  Apr.  15, 
1900). 

Exudative  Chronic  Nephritis. 

Definition. — A  chronic  diffuse  inflam- 
mation of  the  kidneys,  attended  with 
epithelial  degeneration,  exudation  from 
the  blood-vessels,  and  permanent  con- 
nective-tissue changes  in  the  renal 
stroma.  This  is  one  of  two  varieties  of 
chronic  Bright's  disease,  and  is  identical 
with  Delafield's  chronic  productive  (or 
diffuse)  nephritis  with  exudation. 

Symptoms.  —  The  symptoms  of  an 
acute  parenchymatous  nephritis  may 
persist  in  a  lesser  degree  until  the  con- 
dition becomes  a  chronic  one;  particu- 
larly is  this  true  of  the  albuminuria,  the 
ansemia,  and  the  dropsy.  As  a  rule, 
however,  the  disease  develops  slowly  and 
gradually,  and  in  a  subacute  manner, 
although  there  is  seldom  an  early  indi- 
cation of  renal  derangement.  There 
may  be  merely  a  loss  of  appetite,  attacks 
of  indigestion,  nausea,  headache,  dull- 
ness, perhaps  some  pallor,  and  a  general 
impairment  of  health  and  strength.  The 
complexion  then  takes  on  a  blanched 
appearance  and  there  is  soon  puffiness 
of  the  eyelids  or  swelling  of  the  feet  or 


ankles,  or  both.  There  is  a  gradual  ex- 
tension of  the  oedema  up  the  legs,  and 
as  the  day  grows  it  becomes  worse;  on 
rising  in  the  morning  it  may  have  en- 
tirely disappeared.  In  the  majority  of 
cases  the  quantity  of  urine  is  diminished. 
In  the  later  stages  of  the  disease,  how- 
ever, it  may  be  nearly  or  quite  normal, 
and  in  protracted  cases  of  pale  contracted 
Iddney,  or  when  absorption  of  the  drop- 
sical effusion  is  in  progress,  it  may  even 
be  slightly  increased. 

An  acute  nephritis  supervening  upon 
the  chronic  condition  may  now  cause  a 
very  scanty  or  suppressed  secretion  of 
urine.  In  cases  of  scanty  urine  the  spe- 
cific gravity  is,  of  course,  increased,  and 
vice  versa.  Albuminuria  is  often  present 
to  a  decided  degree.  The  albumin  may 
constitute  from  one-fourth  to  three- 
fourths  of  the  urine  in  volume,  or  from 
1  to  3  per  cent,  by  weight;  thus  the 
daily  loss  of  albumin  may  be  consider- 
able. 

The  albuminuria  of  Bright's  disease  is 
always  characterized  by  great  oscilla- 
tions in  the  quantity  of  albumin  ex- 
creted at  different  hours  of  the  day,  be- 
cause either  of  the  richness  of  alimen- 
tation in  nitrogenous  substances  or  of 
causes  that  escape  us  and  should  be 
classed  among  hsematogenous  albumi- 
nurias. Semmola  (Inter,  klin.  Rund., 
Jan.  17,  '89). 

In  many  instances  where  those  au- 
thorities claim  to  obtain  an  albuminous 
reaction  in  normal  urine  they  are  really 
dealing  with  mucin.  Plosz  (Orvosi 
Hetilap,  Nos.  42  and  43,  '90). 

The  clinical  significance  of  albuminuria 
as  a  symptom  has  undoubtedly  dimin- 
ished during  the  last  twenty  years. 
Cases  of  "functional"  albuminuria  con- 
stitute from  one-half  to  one-third  of  all 
the  cases  of  albuminuria  that  come 
under  notice.  Ralfe  (Brit.  Med.  Jour., 
Feb.  20,  '93). 

Six  cases  in  which  autopsy  showed  the 
presence  of  Bright's  disease,  and  in 
which  the  urine,  carefully  examined  dur- 


600 


BRIGHT'S  DISEASE.     EXUDATIVE  CHRONIC  NEPHRITIS.     SYMPTOMS. 


ing  life,  showed,  at  certain  times,  no 
albumin,  although  symptoms  of  ursemia 
were  present.  These  observations,  to- 
gether with  similar  ones  of  Lepine,  Lan- 
cereaux,  and  others,  tend  to  show  that 
albuminuria  is  not  always  a  faithful 
symptom  in  nephritis.  Dieulafoy  (Bull, 
de  I'Aead.  de  Med.  de  Paris,  June  6,  '93). 

Certain  cases  of  Bright's  disease  may 
exceptionally,  and  sometimes  for  a 
rather  long  period,  show  no  albumin  in 
the  urine;  but  there  may  sometimes  be 
renal  insufficiency  without  serious  renal 
lesions.  Too  often  a  case  is  diagnosed  as 
a  contracted  or  enlarged  waxy  kidney, 
when  the  autopsy  shows  but  slight  le- 
sions; diagnosis  should  only  have  been 
renal  insufficiency.  Lgpine  (Lyon  Med., 
July  9,  '93). 

Casts  are  invariably  present  when  a 
true  organic  lesion  exists.  Cardiovas- 
cular tension  is  another  symptom  almost 
invariably  present  in  the  early  stages  of 
renal  cirrhosis.  Occipital  headache,  with 
momentary  attacks  of  vertigo,  is  rarely 
absent.  In  addition,  there  is  usually  a 
somewhat  ill-defined  appearance  of  want 
of  perfect  health,  restless  movements, 
coated  tongue,  foul  breath,  pale  lips,  and 
lifeless  or  waxy  appearance  of  the  skin. 
Danforth  (N.  Y.  Med.  Exam.,  Aug.,  '93). 

Albuminuria  is  absent  in  the  inter- 
stitial forms,  while  the  skin  is  frequently 
dark  in  color  in  the  parenchymatous 
forms.  Dabney  (Inter.  Med.  Jour.,  Nov., 
'93). 

There  is  a  non-albuminuric  nephritis 
exclusive  of  the  cases  of  typical  fibroid 
kidney.  In  this  form  of  nephritis  albu- 
minuria may  be  completely  absent,  while 
signs  of  renal  insufficiency,  and  even 
ursemia,  may  appear.  The  urine  is  di- 
minished and  sometimes  highly  colored, 
but  there  is  no  cardiac  weakness.  Stew- 
art  (Med.  News,  Apr.  14,  '94). 

No  albumin  is  to  be  found  in  the  urine 
in  some  cases  of  nephritis.  Such  a  ne- 
phritis may  be  due  to  the  introduction  of 
a  specific  virus  from  the  external  geni- 
tals. Fienga  (N.  Y.  Med.  Record,  Apr. 
21,  '94). 

Rapid  elimination  of  such  substances 
as  iodide  of  potassium,  quinine,  turpen- 
tine, and  the  bromides  shows  that  the 
kidney    is    healthy,    while    delayed    or 


diminished  elimination  gives  sufficiently 
precise  information  as  to  the  degree  to 
which  the  organ  is  affected.  Bassett 
(N.  Y.  Med.  Record,  Apr.  21,  '94). 

Presence  or  absence  of  albumin  in  the 
urine  is  not  nearly  of  as  much  diagnostic 
and  prognostic  importance  as  the  mor- 
phological   evidence    of    kidney    disease 
afforded  by  the  presence  or  absence  of 
casts.      Ludwig   Bremer    (Med.    Review, 
June  29,  '95). 
The  quantity  of  urea  is  much  dimin- 
ished.   The  urine  contains  an  abundant 
sediment,  consisting  of  urates,  casts,  red 
and    white    blood-corpuscles,    epithelial 
cells,  granular  debris,  and  fatty  granular 
cells,  and  is  in  color  turbid  and  some- 
times  smoky-yellow.     There   are   tube- 
casts  of  different  varieties,  the  narrow 
or  broad  hyaline,   fatty  granular,   and 
epithelial   casts   being  most   commonly 
noted. 

The  oedema  is  prominent  and  persist- 
ent, gradually  extending  all  over  the 
body;  thus  pitting  may  be  obtained  on 
pressure  on  the  limbs,  chest,  abdomen, 
and  back. 

The  loose  subcutaneous  tissues,  as  of 
the  penis,  scrotum,  and  eyelids,  are  es- 
pecially distended.  Only  in  chronic 
hsemorrhagic  nephritis  may  the  oedema 
be  absent  or  very  slight.  Chronic  exu- 
dative nephritis,  especially  with  large 
white  kidney,  shows  a  pasty,  pallid  skin 
and  anasarca  as  its  most  distinguishing 
characteristics.  For  several  months  the 
dropsy  may  be  of  moderate  degree  and 
almost  stationary;  it  then  grows  worse 
insidiously,  in  spite  of  all  efforts  at  treat- 
ment, and  death  ensues  in  a  month  or 
two. 

Case  in  a  man,  50  years  of  age,  in 
whom  cedema  had  occurred  in  various 
positions:  face,  hands,  feet,  and  scro- 
tum. At  one  time  he  was  rather  sud- 
denly seized  with  severe  attack  of 
dyspnoea,  due  to  an  oedema  of  the 
pharyngeal  walls  and  those  of  the  upper 
part  of  the  larynx.    In  the  course  of  sev- 


BRIGHT'S  DISEASE.     EXUDATIVE  CHRONIC  NEPHRITIS.     SYMPTOMS. 


601 


eral  days,  under  the  use  of  a  spray  of 
carbolic  acid  and  an  absolute  milk  diet, 
the  oedema  disappeared.  Mendel  (Ann. 
des  Mai.  de  I'Oreille,  etc.,  May,  '91). 

Form  of  oedema  which  is  to  be  ex- 
cluded in  the  consideration  of  the  symp- 
toms of  Bright's  disease.  It  is  super- 
ficial in  persons  free  from  any  traces  of 
albuminuria  and  unaffected  by  any 
alterations  of  heart  or  lungs.  In  none 
of  the  cases  met  has  the  author  been 
able  to  establish  any  relation  ■^^■ith  the 
htemic  condition,  as  in  chlorosis.  The 
administration  of  iodide  of  potassium 
having  led  to  rapid  disappearance  of  the 
oedema  from  four  cases,  the  phenomenon 
ascribed  to  some  syphilitic  affection 
of  the  vasomotor  system.  Tschirkow 
(Meditzinskoje  Obozrenije,  No.  2,  '91). 

A  large  number  of  cases  in  which 
(Edema  of  the  glottis  was  the  only  symp- 
tom of  Bright's  disease  localized  in  the 
larynx.  Occurs  as  an  incident  in  the 
course  of  the  disease  or  as  the  initial 
symptom  of  latent  Bright's  disease. 
Twelve  such  cases  recorded.  It  may  lead 
to  death  in  several  hours.  Maire-Amero 
(Ann.  des  Mai.  de  I'Oreille,  etc..  Mar., 
•94). 

Three  cases  of  swelling  of  the  eyelids 
associated  with  occasional  albuminuria, 
two  cases  of  occasional  swelling  of  the 
eyelids  but  without  albuminuria,  and 
one  case  of  occasional  swelling  of  the 
eyelids  in  which  albumin  was  always 
present  in  the  urine,  all  in  children.  In 
none  was  there  a  history  of  scarlet  fever. 
These  may  indicate  the  early  stages  of 
insidious  nephritis  with  small  white  kid- 
ney, but  more  likely  only  of  vasomotor 
instability  or  defective  metabolism.  T. 
Fisher  (Brit.  Med.  Jour.,  Apr.  14,  1900). 

There  may  be  present  in  serious  cases 
dropsy  of  the  serous  sacs,  with  its  accom- 
panying distressing  symptoms;  oedema 
of  the  larynx  and  lungs  may  then  super- 
vene, causing  sudden  death.  Dyspncea 
may  occur,  both  toxic  and  nervous,  as 
well  as  mechanical  or  cardiac,  in  origin. 
On  lying  down,  cardiac  dyspnoea,  due  to 
failure  of  the  heart's  action  and  seen  in 
many  instances,  is  aggravated,  as  a  rule. 
Dyspnoea    of   uraemia   is   divided    into 


three  forms:  simple,  characterized  by 
acceleration  of  respiration  and  diminu- 
tion of  the  fullness  of  respiration;  par- 
oxysmal, or  Cheyne-Stokes,  in  which  a 
period  of  apnoea  alternates  with  one  of 
dyspnoea  of  regularly  varying  fullness 
and  the  spasmodic,  which  closely  simu- 
lates spasmodic  asthma.  Lancereaux 
(Jour,  of  Nerv.  and  Mental  Dis.,  May, 
'91). 

In  many  instances  there  is  too  great  a 
tendency  to  regard  as  cardiac  a  toxaemio 
dyspnoea.  In  such  cases  of  dyspnoea, 
where  no  auscultatory  symptoms  are 
present,  even  if  the  urinary  phenomena 
are  not  calculated  to  impress  very 
strongly  the  fact  of  a  decided  renal  alter- 
ation, the  possibility  of  uraemie  origin 
should  be  gravely  considered.  Several 
instances  where  the  withdrawal  of  car- 
diac stimulants  and  morphia,  given  with 
a  view  of  correcting  a  cardiac  error,  and 
the  substitution  of  remedies  and  meas- 
ures for  the  correction  of  a  toxaemia, 
were  followed  by  a  successful  result. 
Landouzy  (Jour,  de  Med.  et  de  Chir. 
Pratiques,  Aug.  10,  '91). 

[It  has  long  been  believed  that  the 
dyspnosa  of  advanced  Bright's  disease  is 
of  toxfemic  origin,  and  so  it  probably 
is  in  a  number  of  instances;  at  least, 
in  a  certain  degree.  But,  aside  from 
the  direct  action  of  the  toxic  retention 
substances  upon  the  respiratoiy  centres 
or  upon  the  respiratory  tissues,  there 
must  be  remembered  the  circulatory  ele- 
ment. Allen  J.  Smith,  Assoc.  Ed., 
Annual,  '92.] 

Attention  called  to  the  many  similar 
features  between  the  dyspnosa  of 
Bright's  disease  and  that  from  accepted 
cardiac  origin,  —  the  breathlessness  on 
even  slight  exertion,  the  distressing 
paroxysms  at  night,  the  influence  of  the 
horizontal  position  in  increasing  the 
severity,  and  the  fact  that  Cheyne- 
Stokes  respiration  is  not  infrequent  in 
either.    Steell  (Med.  Chron.,  Oct.,  '91). 

Particular  attention  to  the  high  arte- 
rial tension  in  cases  of  chronic  Bright's 
disease,  and  to  the  renal  inadequacy 
and  retained  substances  as  an  important 
factor  in  the  etiology  of  the  symptom. 
Musser  (Times  and  Register,  Oct.  17, 
'91). 


602         BEIGHT'S  DISEASE.    EXUDATIVE  CHRONIC  NEPHRITIS.    SYMPTOMS. 


It  may  be  provoked  by  vasoconstric- 
tion, and  is,  in  such  cases,  a  signal  of 
uraemia. 

Form  of  uraemia  which  manifests  itself 
in  the  mouth  and  pharynx:  bucco- 
pharyngeal uraemia.  Marked  by  the 
presence  in  the  mouth  and  pharynx  of 
a  thick,  gummy  mucus,  covering  the 
Malls  of  these  cavities.  When  it  is  de- 
tached the  membrane  beneath  is  red  and 
dry,  but  not  ulcerated,  although  the 
similarity  to  a  pseudomembranous  for- 
mation is  close  enough  to  mislead  the 
incautious.  It  is  not  infrequently  ac- 
companied with  hiccough,  bulbar  dysp- 
noea, and  other  cerebro-spinal  phenomena, 
and  presents  a  number  of  analogies  to 
vomiting  known  to  be  of  central  origin. 
Lancereaux  (Sem.  Med.  and  Gaillard's 
Med.  Jour.,  Mar.,  '91). 

With  these  conditions  may  be  asso- 
ciated catarrhal  bronchitis,  with  cough 
and  expectoration. 

There  is  frequently  a  moderate  degree 
of  cardiac  hypertrophy  of  the  left  ven- 
tricle; later  there  are  dilatation  and 
weakness  of  both  ventricles.  There  is 
an  accentuation  of  the  aortic  second 
sound  and  an  increase  of  the  pulse- 
tension. 

Origin  of  the  cardiovascular  changes 
in  Bright's  disease;  the  hypertrophy  of 
the  heart  is  a  true  hypertrophy  with,  in 
some  cases,  a  mild  interstitial  myocar- 
ditis, the  left  ventricle  alone  being  en- 
larged in  a  little  over  half  of  the  cases, 
the  remainder  showing  enlargement  of 
both  ventricles,  the  right  never  being  en- 
larged alone;  the  changes  in  the  blood- 
vessels are  first  an  inflammation  affect- 
ing the  intima^  and  then  a  secondary 
degeneration  both  of  the  intlma  and 
of  the  muscularis^  which  is  not  hy- 
pertrophied,  even  when  thickened.  Two 
divisions  may  be  made  to  include  the 
cases  of  associated  cardiovascular  and 
renal  disease,  the  first  being  arterio- 
sclerotic in  which  some  irritative  sub- 
stance in  the  blood,  such  as  lead  or 
the  poison  of  gout,  excites  a  primary 
endarteritis  in  the  whole  arterial  sys- 
tem  including  the   kidnev;     the   second 


division  includes  those  cases  in  which  the 
renal  disease  is  primary,  and,  as  the 
damaged  kidneys  are  unable  with  the 
ordinary  rate  of  the  circulation  to  elimi- 
nate all  of  the  products  of  metabolism 
brought  to  them,  those  which  remain  be- 
hind influence  the  heart  through  the 
nervous  system  to  propel  the  blood 
faster,  and  hypertrophy  results;  when 
this  hypertrophy  affects  the  right  ven- 
tricle it  is  the  result  of  the  increased 
blood-supply  to  it;  the  blood-vessels  be- 
come affected  later,  both  by  the  original 
cause  of  the  renal  disease  and  also  by 
the  toxic  state  of  the  blood  due  to  de- 
fective renal  function.  Tyson  (.Jacobi 
Festschrift;  Phila.  Med.  Jour.,  May  26, 
1900). 

Headache,  vertigo,  sleeplessness,  nau- 
sea and  vomiting,  diarrhoea,  and  stupor, 
coma,  or  delirium  may  all  develop  and 
form  the  symptoms  of  a  ursemic  condi- 
tion. 

These  S3'mptoms,  as  a  rule,  precede  a 
fatal  termination.  The  convulsions  that 
are  common  to  chronic  nephritis  without 
exudation  do  not  appear,  however.  In 
quite  a  large  number  of  cases  albumi- 
nuric neuroretinitis  occurs,  and  is  evi- 
denced by  dimness  of  vision  and  field- 
defects.  In  certain  eases  of  marked 
oedematous  distension  the  skin  of  the 
legs  becomes  subject  to  a  red  eezematous 
eruption.  The  temperature  is  practically 
normal  in  the  absence  of  such  complicat- 
ing inflammations  as  pericarditis,  endo- 
carditis; pneumonitis,  and  ulcerative 
colitis,  all  of  which  are  rare  conditions. 

Chronic  exudative  nephritis  may 
either  continue  from  bad  to  worse,  and 
death  may  end  all  in  a  year  or  two,  or 
anaemia,  albuminuria,  and  dropsy  may 
appear  in  a  person  that  has,  for  years 
previously,  enjoyed  apparently  good 
health.  After  a  first  attack  a  second 
proves  fatal  within  a  few  months.  On 
the  other  hand,  certain  cases  may  show 
a  slight  pallor,  a  slightly  diminished 
quantity  of  urine  of  high  specific  gravity. 


BRIGHT'S  DISEASE.     EXUDATIVE  CHRONIC  NEPHRITIS.     ETIOLOGY. 


603 


and  containing  albumin,  and  yet  may 
complain  of  no  inconvenience  for  years. 
Decided  attacks  may  then  occur  at  in- 
tervals, during  which  the  dropsy,  dysp- 
noea, etc.,  may  be  absent,  although  a 
certain  amount  of  albuminuria  persists; 
these  attacks  last  for  several  months. 
The  average  duration  of  the  disease 
varies  from  one  and  one-half  to  three 
years. 

Etiology.  —  Chronic  nephritis  with 
exudation  may  either  follow  acute  diffuse 
nephritis  (as  of  scarlet  fever  or  preg- 
nancy), or  simple  chronic  congestion 
and  chronic  degeneration  of  the  kidneys. 
It  arises  insidiously  more  frequently, 
however,  and  without  any  previous  acute 
manifestation.  Males  are  more  subject 
to  this  form  of  chronic  Bright's  disease 
than  females.  Cases  occurring  in  chil- 
dren are  usually  preceded  more  or  less 
recently  by  scarlatinal  nephritis. 

Heredity  in  chronic  nephritis.    Family 
histoiy  whicli   showed  in   tliree   genera- 
tions  in   one   family   eighteen    cases    of 
chronic  nephritis.     Almost  all  the  mem- 
bers of  the  family  in  these  three  genera- 
tions were  subjects  of  nephritis.     They 
had  the  disease   for  years,  but  reached 
an   advanced   age,   and,   almost   without 
exception,   became  ursemic   and  died   in 
coma.      The    sex    was    equally    divided. 
This  series  indicates  a  hereditary  disposi- 
tion of  the  kidneys  to  become  diseased. 
Pel    (Zeit.  f.  klin.  Med.,  B.  38,  B.  1,  2, 
and  3,  1900). 
Young  adults  are  more  commonly  af- 
fected with  the  usual  form,  developing 
subacutely.      Beer-drinkers,    and    those 
who  are  accustomed  to  using  malt  and 
alcoholic    intoxicants,    seem    especially 
liable  to  the   disease.     Even  in  cases 
where  other  manifestations  are  absent, 
it  is  not  improbable  that,  in  the  in- 
sidious cases,  some  toxic  or  infectious 
agency  may  act  slowly  and  persistently, 
and  be  the  cause  of  the  nephritis. 
The  disease  has  been  observed  in  cer- 


tain individuals  living  in  malarial  re- 
gions, and  persons  working  under  an 
exposure  to  cold  and  wet,  or  living  in 
humid,  marshy  districts,  seem  more 
liable  to  the  renal  malady  than  those 
who  are  more  carefully  shielded  from 
such  influences. 

A  form  of  chronic  albuminuria  of  less 
prognostic  importance  is  that  associated 
with  chronic  malaria.  This  is  probably 
due  to  venous  congestion  during  the  at- 
tacks of  ague.  Lauder  Brunton  (Brit. 
Med.  Jour.,  Feb.  20,  '93). 

Three  cases  of  nephritis  following 
malarial  fever,  in  \Yhich  the  symptoms, 
including  albuminuria,  disappeared  on 
the  administration  of  quinine.  Stephan- 
owicz  (Wiener  klin.  Woch.,  No.  20,  '93). 

Cases  of  parenchymatous  degeneration 
of  kidney,  proved  by  autopsy,  in  which 
the  causative  element  was  chronic  ma- 
larial infection.  A.  Gray  (Jour.  Ark. 
Med.  Soc,  Dec,  '94). 

Case  of  nephritis  in  which  ordinary 
treatment  gave  no  result.  A  character- 
istic access  of  ague  pointing  to  etiology, 
large  doses  of  quinine  caused  rapid  im- 
provement. Bermann  (N.  Y.  Med.  Eec, 
Dee.  23,  '94). 

Acute  form  less  frequent  among  sol- 
diers in  Algeria  and  Tunis  than  in 
France,  showing  the  influence  of  tem- 
perature as  cause;  while  the  reverse  is 
the  case  as  regards  the  chronic  form, 
pointing  to  effect  of  malaria  in  the  eti- 
ology of  Bright's  disease.  Famechon 
(Archives  de  Med.  et  de  Pharm.  Mili- 
taires,  Jan.,  '95). 

Conclusions  to  be  drawn  from  a 
study  of  the  relation  of  chronic  nephritis 
to  malarial  disease:  In  some  localities 
malarial  fever  should  be  given  a  promi- 
nent position  in  the  etiology  of  chronic 
as  well  as  of  acute  nephritis.  In  all 
cases  of  malarial  fever  the  urine  should 
be  closely  watched.  A  blood-examina- 
tion should  be  made  in  all  cases  of  ne- 
phritis occurring  in  those  who  have 
visited  or  lived  in  a  malarial  district, 
as  it  often  happens  that  the  severe  grade 
of  nephritis  resulting  may  mask  entirely 
the  clinical  picture  of  malarial  fever.     C. 


604        BRIGHT'S  DISEASE.     EXUDATIVE  CHRONIC  NEPHRITIS.     PATHOLOGY. 


W.  Larned   (Johns  Hopkins  Hosp.  Bull., 
July,  '99). 

This  so-called  "parenchymatous"  form 
of  chronic  Bright's  disease  may  find  its 
cause  in  tuberculosis,  syphilis,  or  chronic 
suppuration,  and  in  such  cases  it  is  usu- 
ally combined  with  amyloid  disease 
(waxy  degeneration). 

Epithelial  nephritis  may  follow  in  the 
course  of  syphilis,  tuberculosis,  and  lep- 
rosy, and  which  are  quite  distinct.  It 
begins  suddenly,  as  does  subacute  nephri- 
tis, but  its  progress  is  slow.  The  urine 
is  not  abundant,  is  strongly  albuminous, 
and  the  prognosis  always  gi-ave  on  ac- 
count of  the  danger  of  uraemia.  Lan- 
cereaux   (Le  Bull.  Med.,  Jan.  11,  '93). 

Syphilis  may  lead  to  a  nephritis  re- 
bellious to  treatment.  Dieulafoy  (Bull, 
de  I'Acad.  de  Med.  de  Paris,  June  20, 
'93). 

Case  developed  suddenly  without  usual 
causes,  during  seeondaiy  period  of  syph- 
ilitic infection.  Thiroloix  (Concours 
M6d.,  July   13,  '95). 

The  nature  of  chronic  nephritis:  1. 
The  different  forms  of  Bright's  disease 
are  to  be  regarded  as  various  stages  in 
the  same  general  process,  there  being  a 
unity  pervading  the  whole  pathological 
picture.  2.  All  forms  of  nephritis  are 
due,  in  the  immense  majority  of  oases, 
to  infective  agents;  the  acute,  to  the 
usual  specific  germs  of  the  primary  dis- 
ease, and  the  chronic,  as  a  general  rule, 
to  the  bacillus  coli,  though  other  germs 
may  sometimes  be  concerned.  3.  Acute 
Interstitial  inflammation  and  subsequent 
connective-tissue  hyperplasia  are  the  key- 
note of  the  process;  this  is,  however, 
preceded  by  parenchymatous  degenera- 
tion. 4.  The  point  of  invasion  by  the 
bacillus  coli  is  the  gastrointestinal 
tract;  those  of  other  germs  may  be 
various.  5.  The  liver  and  mesenteric 
glands  are  the  first  barriers  of  defense; 
and  the  endothelial  cells  of  the  capillaries 
and  the  secreting  tubules  of  the  kidney 
have  the  power  of  ingesting  bacteria,  this 
being  an  attempt  at  inhibition  and  elimi- 
nation. A.  G.  Nieholls  (Montreal  Med. 
Jour.,  Mar.,  '99). 

Pathology.  —  There  are  several  types 


of  kidney  included  in  this  disease,  yet 
in  all  the  changes  of  structure  are  essen- 
tially identical,  and  the  variations,  when 
they  occur,  depend  upon  the  cause  and 
duration  of  the  nephritis. 

The  large  white  kidney  (without  waxy 
degeneration)  may  be  either  normal  in 
size  or  enlarged,  and  is  pale  or  yellow- 
ish in  color.  The  surface  is  smooth  and 
the  capsule  is  easily  stripped  off.  On 
section  the  cortex  appears  broader  than 
normally,  and  is  either  yellowish  white 
throughout  or  may  present  opaque  yel- 
lowish or  whitish  areas  with  mattings  of 
red.  In  some  cases  the  pyramids  are 
congested.  The  following  changes  may 
commonly  be  observed  microscopically: 
The  renal  epithelium  is  swelled,  hyaline, 
granular,  or  fatty,  and  is  more  or  less 
disintegrated  or  flattened;  there  is  an 
enlargement  of  the  glomeruli,  awing  to 
the  growth  of  the  capsule-cells  and  of 
the  cells  covering  the  capillaries;  and, 
in  certain  cases,  as  a  result  of  the  con- 
nective-tissue thickening  of  the  capsule, 
the  tuft  of  capillaries  is  atrophied.  There 
is  some  thickening  of  the  arterial  walls, 
and  a  moderate  growth  of  connective- 
tissue  may  be  noted  in  patches  around 
the  glomeruli  and  tubules.  The  latter 
contain  hyaline  and  granular  casts. 

The  small  white  kidney  (secondary 
contracted  kidney)  is,  in  most  instances, 
probably  a  later  stage  of  the  preceding 
condition,  in  which  the  epithelial  degen- 
eration becomes  more  pronounced,  and 
the  connective-tissue  growth  and  the 
resultant  cicatricial  contraction  become 
prominent  features.  The  kidneys  are 
about  normal  in  size;  owing  to  a  shrink- 
age in  the  large  white  kidney,  the  sur- 
face is  slightly  granular  and  the  capsule 
proportionately  adherent.  In  color  they 
are  usually  grayish  or  yellowish  (pale 
granular),  and  there  may  be  a  certain 
amount  of  red  mottling.     The  consist- 


BRIGHT'S  DISEASE.     EXUDATIVE  CHRONIC  NEPHRITIS.     TREATilENT. 


605 


ency  is  firmer  than  that  of  the  large 
white  kidney,  and  the  surface,  on  sec- 
tion, shows,  in  the  somewhat  narrowed 
cortex,  yellowish-white  foci  of  fatty- 
degenerated  epithelium;  hence  the  term 
"small,  granular,  fatty  kidney."  Micro- 
scopically we  find  extensive  degeneration 
and  disintegration  of  the  epithelium  of 
the  glomeruli  and  convoluted  tubules, 
atrophy  of  the  parenchyma,  and  a  cor- 
responding increase  in  the  interstitial 
connective  tissue.  There  may  be  an  as- 
sociated waxy  degeneration. 

The  large  red  or  variegated  kidney  of 
chronic  hemorrhagic  nephritis  forms  a 
third  variety.  The  kidneys  are  found, 
as  a  rule,  enlarged,  red,  swelled,  and  con- 
gested-looking or  mottled;  frequently 
they  are  "bumpy,"  or  slightly  bosselated. 
The  capsule  is  slightly  adherent  to  the 
depressions  between  the  bosses.  The  sec- 
tion shows  congested  portions  and  gray 
or  yellow  spots  corresponding  to  the 
ansemic  and  fatty-degenerated  portions. 
Eed  spots,  due  to  small  hsemorrhage,  may 
also  be  noticed  on  both  the  outer  and 
cut  surfaces  of  the  kidney,  and  small 
cortical  hemorrhagic  areas  or  striations, 
brownish-red  in  color,  are  distinctive. 
Microscopically  the  appearances  are  those 
of  acute  nephritis  superadded  to  those  of 
the  large  white  kidney,  and  consist  of 
fatty  granular  degeneration,  epithelial 
proliferation,  atrophied  capillary  tufts, 
thickened  glomeruli  capsules,  and,  in 
some  places,  a  growth  of  interstitial 
fibrous  tissue.  In  either  place  inflam- 
matory cedema  and  celhilar  infiltration 
of  the  intertubular  tissue  may  be  noted, 
as  well  as  the  dilated  tufts  of  capillaries 
with  surrounding  cellular  hyperplasia. 
This  variety  of  chronic  nephritis  is  fre- 
quently seen  in  inebriates. 

Prognosis.  —  The  prognosis  is  invari- 
ably bad,  though  life  may,  in  certain 
eases,  be  prolonged.     Death  may  occur 


in  severe  cases  in  from  three  months  to 
a  year,  from  urjemia,  dropsy,  dilatation 
of  the  heart,  or  from  other  complica- 
tions. Cases  of  a  year's  duration  seldom 
recover,  and  those  in  which  advanced 
secondary  contraction  of  the  kidney  may 
be  assumed  may  be  considered  hopeless; 
they  often  terminate  suddenly.  Earely 
there  may  be  a  complete  recovery;  this 
occurs  particularly  in  children  following 
an  attack  of  scarlet  fever.  According 
to  the  quantity  of  urine  passed  in  the 
twenty-four  hours,  and  the  amount  and 
persistence  of  the  albumin,  is  the  prog- 
nosis made,  as  well  as  upon  the  degree 
of  cardiovascular  and  retinal  changes. 
Eelapses  may  occur  in  apparently  favor- 
able cases,  and  acute  attacks  may  super- 
vene. 

Study  of  several  hundred  of  cases  of 
nephritis  has  shown  that  chronic  ne- 
phritis is  not  an  incurable  disease;  re- 
covery occurs  in  rare  cases.  It  may 
exist  for  years  without  causing  ap- 
parent constitutional  disturbance.  The 
average  duration  in  three  hundred  and 
thirty-two  cases  of  chronic  nephritis 
was  nineteen  months.  Acute  nephritis 
is  less  common  than  has  been  sup- 
posed; many  cases  that  were  formerly 
so  classified  are  found  to  represent 
exacerbations  of  chronic  nephritis.  R.  C. 
Cabot  and  F.  W.  White  (Boston  Med. 
and  Surg.  Jour.,  Aug.   10,  '99). 

Treatment. — This  is  conducted  much 
as  in  acute  nephritis.  The  uremia  and 
dropsy  are  treated  symptomatically.  The 
diet  is  of  great  moment,  skimmed  milk 
and  buttermilk  being  depended  on  as 
much  as  possible  when  the  dropsy  is 
marked.  When  the  dropsy  is  slight, 
more  solid  food,  white  meats,  vegetables, 
and  fruits,  and  an  out-door  life  should 
be  recommended.  Prolonged,  sudden 
exercise  and  severe  exercise  should  be 
prohibited. 

Importance  of  combating  the  tendency 
to  anaemia,  the  prognosis  remaining  good 


606       BRIGHT'S  DISEASE.    NON-EXUDATIVE  CHRONIC  NEPHRITIS.    SYMPTOMS. 


as  long  as  this  condition  is  averted. 
Stephen  Mackenzie  (Brit.  Med.  Jour., 
Feb.  20,  '93). 

Woolens  should  be  worn  next  to  the 
skin,  and  residence  in  a  warm,  dry  cli- 
mate may  aid  in  extending  life. 

Nitroglycerin  may  be  needed  in  cases 
with  contracted  and  tense  arteries,  with 
a  tendency  to  ursemic  twitehings,  and 
digitalis  may  be  useful  in  cardiac  weak- 
ness. Basham's  mixture  for  the  ansemia 
and  unirritating  diuretics  will  prove  of 
value,  and  strontium  lactate,  in  doses  of 
from  15  to  20  grains,  three  or  four  times 
daily,  may  be  tried  in  some  cases. 

Three  cases  of  nephritis  treated  by 
lactate  of  strontium;  an  excellent  diu- 
retic in  the  acute  forms  and  in  acute 
attacks  occurring  in  the  course  of  the 
chronic  form.  Da  Costa  (Med.  News, 
Apr.  21,  '94). 

Child,  5  years  of  age,  who  suffered 
from  chronic  Bright's  disease  and  whose 
urine  contained  large  quantities  of 
serum-albumin  and  globulin.  Lactate  of 
strontium  increased  the  quantity  of 
urine  and  solids  excreted  and  the  pa- 
tient rapidly  recovered.  Gillespie  (Med. 
Chronicle,  Sept.,  '94). 

Lactate  of  strontium  is  beneficial,  in 
a  large  number  of  cases,  when  sclerosis 
has  not  begun.  It  produces  nausea  in 
powder,  but  not  when  dissolved  in  water, 
1  to  6  parts,  three  or  four  tablespoonfuls 
being  given  daily.  Ried  (Med.  and 
Surg.  Reporter,  Jan.  26,  '95). 

Lactate  of  strontium  tried  in  10  cases 
of  Bright's  disease :  3  of  acute  parenchy- 
matous, 6  mixed,  and  1  interstitial.  The 
favorable  action  of  salts  of  strontium  on 
the  kidneys  is  not  due  to  their  dimin- 
ishing putrefaction  in  the  intestines. 
Direct  experiments  with  bacteria  show- 
ing that  the  antiseptic  properties  of  lac- 
tate of  strontium  are  insignificant,  and 
that  the  presence  of  ethero-sulphurie 
acids  in  the  urine  is  not  influenced  by 
the  use  of  the  drug.  Bronowski  (Medy- 
cyna.  No.  1,  '96). 

There  is  a  great  deal  of  mischief  done 
by  iron  in  Bright's  disease.  It  may  be 
laid  down  as  a  rule  to  ■which  there  is 


almost  no  exception  that  tlie  iron  is  not 
indicated,  and  should  not  be  prescribed, 
in  cases  of  acute  Bright's  disease.  On 
the  other  hand,  after  the  acute  symptoms 
have  passed  away  and  convalescence  sets 
in,  iron  is  very  useful.  A  second  class  of 
cases  in  which  iron  is  contra-indicated  is 
chronic  interstitial  nephritis,  in  which  it 
is  more  promptly  and  dangerously  harm- 
ful than  in  any  other  form  of  Bright's 
disease.  The  form  of  Bright's  disease  in 
which  iron  is  best  borne  is  chronic  paren- 
chymatous nephritis.  The  proper  dose 
should  be  determined  by  an  examination 
of  the  stools,  and,  if  these  are  decidedly 
blackened,  too  much  is  being  given. 
Basham's  mixture  is  no  more  diuretic 
than  the  bulk  of  water  which  constitutes 
its  menstruum.  James  Tyson  (Journal 
Amer.  Med.  Assoc,  July  23,  '98). 
Methylene  has  also  given  satisfaction 
in  some  cases. 

Methylene-blue     is     recommended     in 
chronic   nephritis.      Dose,    from    3    to    5 
grains  a  day.    Man  of  58  years,  suffering 
from'  chronic  Bright's  disease  with  renal 
congestion    and    albuminuria,    was    ad- 
mitted to  the  hospital.     On  the  25th  of 
February  he  was  passing  six  grammes  of 
albumin  a  day.    He  was  given  a  modified 
milk   diet   and   treatment  with   alkalies 
and  tannin.     Shortly  afterward  he  was 
placed   upon   methylene-blue   in   dose   of 
4  grains  a  day.     On  the  3d  of  March  he 
was  passing  four  grammes  of  albumin; 
four    days    later    he    was    passing    two 
grammes;     and   on  March    10th   he  was 
passing  20  grains.     Lemoine    (Jour,  des 
Praticiens,  May  22,  '97). 
Non-exudative  Chronic  Nephritis. 
Definition. — A  chronic  diffuse  inflam- 
mation of  the  kidneys,  indicated  by  a 
growth  of  connective  tissue  in  the  stroma, 
degeneration  and  atrophy  of  the  renal 
parenchyma,  and  by  marked  changes  in 
the  cardiovascular  system. 

Symptoms.  —  The  symptoms  may  re- 
main latent  for  a  considerable  time,  even 
for  years,  while  the  morbid  productive 
changes  are  gradually  effected  in  the 
kidneys.  They  may  not  become  evident 
until  late  in  life,  even  though  the  kid- 


BRIGHT'S  DISEASE.    NON-EXUDATIVE  CHKONIC  NEPHRITIS.    SYMPTOMS.      607 


neys  may  be  in  an  advanced  state  of 
degeneration.  Some  complicating  condi- 
tion may  also  supervene,  as  pericarditis 
or  pneumonia,  causing  the  development 
of  grave  renal  symptoms.  As  a  rule, 
however,  ursmia  makes  its  appearance 
with  headache,  stupor,  or  convulsions, 
dyspnoea,  nausea  and  vomiting,  and  a 
tense  pulse.  This  seizure  may  be  re- 
covered from.  There  is  now  an  interim, 
of  variable  duration,  in  which  there  are 
drowsiness,  lassitude,  a  disordered  diges- 
tion, headache,  failing  vision,  dyspnosa, 
and  frequent  micturition,  with  a  more  or 
less  impaired  general  health.  Then  fol- 
lows another  uraemic  seizure,  still  more 
severe,  if  not  fatal.  If  not  fatal,  the 
general  health  is  still  more  reduced,  and 
confinement  to  the  house  or  bed  is  nec- 
essary; at  last  the  vital  forces  can  no 
longer  compensate  for  the  destruction  of 
the  renal  parenchyma.  Contracted  kid- 
ney may  sometimes  first  be  manifested 
by  spasmodic  dyspnoea  (urEemic-cardiac). 
There  is  a  marked  gradual  onset  of 
periods  of  drowsiness  during  the  day 
that  are  uncontrollable;  an  attack  of 
hemiplegia  may  be  the  first  sign  of  the 
disease.  In  other  cases  a  progressive  loss 
of  flesh  and  strength,  with  a  dry,  harsh, 
wrinkled  skin,  may  be,  from  the  begin- 
ning, the  only  clinical  features,  until 
death  results  from  sheer  feebleness  and 
emaciation.  The  variability  and  involve- 
ment of  the  symptoms  render  it  advis- 
able to  describe  them  under  the  various 
systemic  divisions. 

There  is  an  increase  in  the  daily  quan- 
tity of  urine  excreted  so  great  that  it 
causes  a  frequent  desire  to  micturate, 
not  only  during  the  day-time,  but  two 
or  three  times  through  the  night.  This 
may  be  aggravated  by  the  hyperacidity 
of  the  urine  and  by  the  irritability  of  the 
prostate  gland  (especially  in  advanced 
years)  that  are  so  often  associated  with 


renal  cirrhosis.  The  total  quantity  of 
urine  for  the  twenty-four  hours  may 
measure  several  quarts  in  marked  cases 
of  the  disease.  It  may  be  slightly  de- 
creased early  in  the  attack,  when  the 
degeneration  and  destruction  of  the  par- 
enchyma are  in  their  incipiency;  but,  as 
the  "blood-flow  to  the  parts  that  remain 
must,  cceteris  paribus,  be  as  great  as  it 
would  have  been  to  the  whole  of  the 
organs  if  they  had  been  intact,"  excess- 
ive pressure  is  brought  to  bear  within 
the  capillaries,  owing  to  the  compensat- 
ing cardiac  hypertrophy,  and  the  secre- 
tion of  the  urine,  especially  of  the  watery 
elements,  becomes  more  active.  Diabetes 
may  be  suggested  by  the  polyiiria,  but 
the  urine  is  clear  and  pale-yellow  in 
color,  the  specific  gravity  being  seldom 
above  1010  or  1012,  and  it  may  be  as 
low  as  1002  or  1005.  Albumin  occurs 
in  traces  only,  or  may  even  be  absent 
altogether  (glomerular  atrophy);  this  is 
noted  especially  in  the  urine  voided  in 
the  early  morning.  The  urea  is  dimin- 
ished, and  there  is  little  or  no  sediment. 
On  careful  examination,  microscopically, 
there  may  be  found  a  few  casts  (usually 
narrow  hyaline),  perhaps  some  leuco- 
cytes, and,  rarely,  a  few  red  blood-cells. 
Late  in  the  disease  or  in  the  presence  of 
a  uraemic  exacerbation  or  a  complicating 
inflammation,  the  urine  may  be  dimin- 
ished in  quantity,  the  albumin  increased, 
and  numerous  casts  be  found  in  the  more 
apparent  sediment.  Hematuria  is  a  rare 
condition. 

Epistaxis  may  form  a  serious  symptom. 

Case  of  cerebral  hsemorrhages  in  ad- 
vanced Bright's  disease.  Symptoms  of 
the  chronic  interstitial  form  with  marks 
of  a  slight,  old,  retinal  haemorrhage.  One 
night  the  patient  became  quickly  sleep- 
less and  delirious,  and  was  found,  the 
following  morning,  in  a  comatose  condi- 
tion. His  temperature  was  slightly  sub- 
normal;   there  were  no  convulsions;    the 


608 


BRIGHT'S  DISEASE.    NON-EXUDATIVE  CHRONIC  NEPHRITIS.    SYMPTOMS. 


bladder  was  not  distended;  pulse,  80, 
small,  compressible;  pupils  equal,  a  little 
dilated,  reacting  to  light ;  no  strabismus ; 
no  paralysis.  Croton-oil  was  given,  and 
hypodermics  of  pilocarpine;  but  the 
coma  deepened,  the  breathing  becoming 
stertorous,  the  chest  filling  with  rales, 
and  pulse  and  respirations  failed  almost 
synchronously.  At  post-mortem,  to  the 
left  of  the  aqueduct  of  Sylvius,  there 
was  a  small  hcemorrhage,  of  the  size  of 
a  pea,  flattened  from  above  downward  in 
its  site  in  the  pontine  part  of  the  floor 
of  the  fourth  ventricle.  Walsh  (Med. 
Press  and  Cir.,  Nov.  26,  '90). 

Epistaxis  in  Bright's  disease  due  to  a 
sanguine  dyscrasia,  to  alterations  of  the 
vessels  supplying  the  nasal  mucous  mem- 
brane, to  cardiac  hypertrophy,  and  to 
increased  arterial  tension.  Occurs  most 
frequently  in  the  interstitial  form  of 
Bright's  disease,  and  is  apt  to  appear 
principally  at  the  beginning  and  at  the 
end  of  the  malady.  Sometimes  it  is  the 
first  sign  which  excites  a  suspicion  of 
the  affection.  Savemy  (These  de  Paris, 
'91). 

Conditions  in  which  hfemorrhage  may 
occur  in  Bright's  disease:  high  tension, 
modifications  in  the  structure  of  the 
arteries,  and  hypertrophy  of  the  heart. 
Potain  (Jour,  de  M6d.  et  de  Chir.  Pra- 
tiques, Aug.  10,  '94). 

Importance   of   haemorrhage  from   the 
nose  and  into  the  ear  as  early  manifes- 
tations of  Bright's  disease.     Illustrative 
case.    The  so-called  cases  of  spontaneous 
or  idiopathic  hsemorrhages  into  the  ear 
ought  all  to  be  carefully  investigated  as 
to  the  possibility  of  an   underlying  ne- 
phritic cause.    He  would  speak  of  a  tym- 
panitis or  myringitis  albuminurica,  just 
as   we    speak    of   rhinitis    albuminurica. 
Haug    (Deutsche   med.    Woch.,    Nov.    5, 
'96). 
Sudden  oedema  of  the  larynx  may  also 
supervene,  and  is  always  a  grave  condi- 
tion.   Transudations  into  the  pleural  sac 
(hydrothorax)  and  the  lungs  may  pre- 
cede the  fatal  termination.    Dyspnoea  is 
either  ursemic  or  cardiac  and  is  usually 
worse  at  night;   a  true  orthopnoea,  with 
Cheyne-Stokes   breathing,   may   be    ob- 


served in  association  with  uremic  stupor 
and  coma,  and  near  the  end  of  the  pa- 
tient's life. 

The  signs  of  hypertrophy  of  the  heart 
(particularly  of  the  left  ventricle)  may 
be  elicited,  though  symptoms  referable 
to  the  heart  itself  are  absent,  unless  dila- 
tation and  feebleness,  sudden  arterial 
contraction,  or  endocarditis  occur.  In- 
spection and  palpation  show  the  apex- 
beat  to  be  displaced  downward  and  to 
the  left,  and  the  impulse  to  be  increased, 
heaving,  and  rather  circumscribed.  In 
cases  of  co-existing  emphysema,  and 
later,  when  dilatation  may  eclipse  the 
hypertrophy,  these  signs  may  become 
less  evident.  The  left  border  of  deep 
cardiac  dullness  extends  outside  the 
nipple-line  in  the  fifth  or  sixth  inter- 
space. The  first  sound  of  the  heart  is 
loud  and  may  be  reduplicated.  Accent- 
uation of  the  aortic  second  sound  is  a 
distinctive  sign,  and  indicates  increased 
vascular  tension;  it  may  have  a  metallic 
quality  in  some  cases.  There  may  also 
develop  a  mitral  systolic  murmur  as  the 
result  of  relative  insufficiency.  There  is 
increased  tension  of  the  pulse,  the  latter 
being  hard,  persistent,  and  incompress- 
ible; the  pulse-wave  is  also  increased  in 
duration  (pulsus  tardus).  Most  of  the 
palpable  arteries  are  hard,  thickened, 
and  tortuous,  owing  to  the  arterioscle- 
rosis. As  soon  as  compensation  fails, 
symptoms  of  breathlessness  on  exertion, 
palpitation,  and  the  like,  appear;  often 
these  occur  in  paroxysms  and  constitute 
"cardiac  asthma."  The  resulting  stasis 
causes  a  transudation  into  the  lungs 
(bronchorrhcea,  pulmonary  oedema)  and 
later  to  osdema  of  the  extremities. 

Of  106  fatal  cases  of  chronic  (intersti- 
tial) nephritis,  20  died  from  cerebral 
hsemorrhage;  in  all  of  these  cases  both 
kidneys  were  diseased,  cedema  of  the 
extremities  not  being  recorded  in  a  single 


BRIGHT'S  DISEASE.    NON-EXUDATIVE  CHRONIC  NEPHRITIS.    SYMPTOMS. 


609 


instance  and  oedema  of  the  lungs  in  only 
2,   thus   showing   that  all   was  going  on 
well    until    the    fatal    rupture.     The    re- 
maining cases  died  from  oadema,  princi- 
pally  involving  the   lungs   and   pleurjE. 
OSdema  is,  therefore,  the  most  common 
cause   of   death;     this    occurs   in    conse- 
quence of  the  stretching  of  the  auriculo- 
venbricular  orifice,   allowing  of  regurgi- 
tation.     A    mitral    murmur    is    by    no 
means  always  present.    Arterial  sclerosis 
is  marked  in  the  cases  dying  from  cere- 
bral   haemorrhage,    and    this    might    ac- 
count for  the  non-dilatation  of  the  au- 
riculo-ventricular    orifices.      The    heart- 
sounds  assumed  a  clanging  tone  in  sev- 
eral instances  preceding  the  fatal  result 
observed.      Hawkins   and    Russell    Dodd 
(Clinical  Soc.  of  London;    Annual,  '94). 
Since  they  are  indicative,  as  a  rule, 
of  grave  urjemia,  the  symptoms  referable 
to  the  nervous  system  are  of  great  im- 
portance.   There  may  be  neuralgic  pains 
throughout  the  body,  and  insomnia,  and 
cephalalgia    is    frequent.      Later    great 
drowsiness    is    often    a    premonition    of 
ursemic  coma.    Muscular  twitchings  may 
precede  convulsions,  and  should  attract 
attention  to  the  imminent  danger.    Cere- 
bral apoplexy  with  hemiplegia  may  form 
the  first  symptom  of  contracted  -kidney, 
and  is  apt  to  occur  in  cases  of  marked 
hardening  and  weakening  of  the  arteries. 
Hemorrhagic  pachymeningitis  and  hsem- 
orrhage   into    the   brain-substance    may 
also    occur.     The   hemiplegia   may   last 
until  the  end,  or  it  may  disappear  soon 
and  be  followed  by  subsequent  attacks 
at  intervals.     Dieulafoy  believes  numb- 
ness, formication,  and  pallor  of  the  fin- 
gers ("dead  finger")  to  be  sometimes  the 
earliest    symptoms   of   chronic    Bright's 
disease. 

The  dead  finger  is  a  vascular  trouble 
in  cardiac  disease,  or  an  hysterical  phe- 
nomenon, and  has  nothing  to  do  with 
Bright's  disease.  The  principal  sign  of 
renal  insufficiency  is  the  toxicity  of  the 
urine.  The  excretion  of  nitrogen  in  con- 
siderable quantity  by  the  faeces  is  also 

1- 


a  good  sign.  G.  See  (Bull,  de  I'Aead. 
de  Med.  de  Paris,  June  27,  '93). 
Of  the  symptoms  referable  to  the 
special  senses  nephritic  retinitis  often 
forms  the  earliest  evidence  of  chronic 
Bright's  disease.  There  may  or  may  not 
have  been  present  a  slight  dimness  of 
vision  prior  to  the  ophthalmoscopical 
examination.  There  is  a  partial  loss  of 
vision  in  both  eyes  (amblyopia),  and  in 
grave  cases  sudden  and  complete  blind- 
ness may  come  on  (ursmic  amaurosis; 
as  the  result  of  a  neuroretinitis.  The 
optic  papilla  is  swelled,  and  surrounded 
by  retinal  haemorrhages  or  by  white  dots 
and  streaks  ("feather-splashes"). 

The  varieties  of  albuminuric  retinitis 
are  (1)  neuritis  (optic  papillitis,  or  in- 
terstitial neuritis  with  swelling  and 
round-cell  infiltration  of  the  connective 
tissue  of  the  nerve,  leading,  in  some 
cases,  to  atrophy  of  the  nerve-fibres). 

(2)  Neuroretinitis,  in  which  the  retinal 
expansions  of  the  optic  nerve  become 
swelled  and  ultimately  granular  and 
fatty.  With  these  changes  are  associated 
A\hite  patches,  of  which  there  are  tW'O 
kinds:  («)  rounded,  soft-edged  areas  of 
lymph-exudation  and  (6)  smaller,  bright, 
radiated  streaks  or  specks.  The  latter 
are  mostly  seen  radiating  from  the  yel- 
low spot.  Their  glistening  appearance  is 
due  to  the  refractive  power  of  the  minute 
oil-globules  of  Avhich  they  consist. 

(3)  Periarteritis;  chiefly  affecting  the 
outer  coats  of  the  arteries,  and  causing 
them  to  become  thickened,  and  to  en- 
croach on  the  lumen  so  as  to  obliterate 
the  smaller  ones.  This  condition  is  asso- 
ciated with  haemorrhages  and  capillary 
dilatations. 

(4)  Diffused  opacity  of  the  retina  from 
oedema. 

Diagnosis:  None  of  the  ophthalmic  ap- 
pearances described  are  pathognomonic 
of  Bright's  disease.  Similar  forms  of 
neuritis  and  neuroretinitis  are  met  with 
in  cases  of  cerebral  tumor,  while  haemor- 
rhages may  occur  in  cases  of  leucoeythas- 
mia,  chlorotie  and  pernicious  anaemia, 
and  purpura.  Multiple  retinal  periar- 
teritis, though  generally  associated  with 
39 


610       BRIGHT'S  DISEASE.    NON-EXUDATIVE  CHRONIC  NEPHRITIS.    SYMPTOMS. 


nephritis,  is  met  with  apart  from  this 
condition.  The  ophthalmoscopical  ap- 
pearance must  always  be  confirmed  by 
some  of  the  more  obvious  signs  of 
Bright's  disease. 

Causation:  Four  causes:  (1)  dys- 
crasia,  or  altered  condition  of  the  blood; 
(2)  secondary  degenerative  changes  in 
the  small  blood-vessels;  (3)  excessive 
pressure  of  blood  within  the  vessels;  (4) 
an  inflammatory  process  of  the  affection 
of  both  vessels  and  nerves.  Many  re- 
gard the  changes  as  purely  degenerative. 

Prognosis:  The  gi'ave  class  of  cases 
includes  diffuse  neuroretinitis,  radiating 
patches  around  the  yellow  spot,  and  mul- 
tiple periarteritis.  These  are  most  com- 
mon in  contracting  granular  kidney. 
When  the  changes  are  marked  he  would 
place  the  extreme  duration  of  life  at  two 
years,  whatever  the  state  of  the  general 
health  might  be. 

An  exception  to  this  rule  is  in  the  case 
of  puerperal  nephritis.  Here  the  condi- 
tion mainly  depends  on  pre-existing  dys- 
crasia  of  the  blood,  of  which  the  retinal 
changes  are  only  another  local  expres- 
sion. Recovery  is  general,  if  pregnancy 
does  not  recur.  The  dyserasia  is  not  de- 
pendent solely  upon  renal  disease. 

The  benign  class  of  cases  includes 
simple  oedema,  hsemorrhages,  and  soft- 
edged  patches.  All  these  conditions  may 
subside,  and  their  presence  does  not 
make  the  prognosis  of  the  case  better  or 
worse. 

One  may  conclude,  therefore,  that  the 
prognosis  is  based  upon  the  nature  of 
the  ophthalmoscopical  changes  discov- 
ered, and  upon  the  nature  of  the  ne- 
phritis which  caused  them. 

In  interstitial  nephritis,  retinitis  is  a 
measure  of  the  general  amount  of  vas- 
cular degeneration  present.  Advanced 
retinitis  characteristic  of  interstitial 
nephritis,  together  with  other  signs  of 
that  disease,  mean  a  speedy  death. 

On  the  other  hand,  signs  of  retinitis 
equally  characteristic  of  other  forms  of 
nephritis  are  due  to  toxfemia  rather  than 
to  vascular  degeneration,  and  as  such 
may  be  cured.  Saundby  ("Lectures  on 
Renal  and  Urinaiy  Diseases,"  '90;  from 
review  in  Treatment,  June  24,  '97). 


Tinnitus  aurium,  deafness,  and  vertigo 
are  not  uncommonly  present. 

Nausea,  anorexia,  and  dyspepsia  are 
frequent  conditions.  Severe  vomiting 
may  precede  an  attack  of  uraemia. 
Ursemic  diarrhoea  may  occur,  and  there 
may  also  exist  a  catarrhal  gastritis  for 
some  time,  the  tongue  being  thickly 
coated  and  the  breath  heavy  and  urin- 
ous. 

Case  in  which  the  existence  of  a  typh- 
litis was,  for  a  time,  suspected;  true 
nature  of  the  case  declared  by  a  ursemic 
headache  accompanied  by  blindness. 
Second  case  in  which  the  cephalalgia  was 
the  most  marked  feature.  These  intes- 
tinal derangements  characterize  so  large 
a  class  of  urtemics,  the  disturbance  being 
generally  of  the  nature  of  diarrhoea,  that 
practitioners  should  constantly  suspect 
those  seeking  treatment  for  persistent 
alimentary  troubles  of  being  affected 
with  an  underlying  nephritis.  Taylor 
(Cincinnati  Lancet-Clinic,  Nov.  15,  '90). 

Examination  of  the  conditions  of  the 
stomach  in  twenty-six  cases  of  chronic 
parenchymatous  and  interstitial  nephri- 
tis, mostly  in  middle-aged  patients,  show- 
ing that  renal  disease  has  a  marked  in- 
fluence upon  the  chemistry  of  gastric 
digestion.  Kravkoff  (London  Med. 
Recorder,  Jan.  20,  '91). 

Action  of  various  constituents  of  the 
urine  upon  intestinal  peristalsis.  It  is 
probable  that,  among  the  substances  re- 
tained, there  is  some  substance  directly 
paralyzant  to  intestinal  movement.  It 
is  not  a  very  uncommon  occurrence  to 
have  the  ursemio  diarrhoea  followed  by 
a  condition  of  intestinal  paralysis,  and 
cases  of  uraemia  have  unwittingly  been 
operated  upon  for  the  relief  of  a  sup- 
posed intestinal  obstruction.  Hirschler 
(Wiener  med.  Woch.,  Mar.  21,  '91). 

Warning  against  the  administration  of 
an  opiate  in  any  diarrhoeal  patient  above 
50  years  of  age,  owing  to  the  untoward 
effect  of  opium  in  cases  of  renal  insuffi- 
ciency. Musser  (Times  and  Register, 
Oct.  17,  '91). 

Digestive  troubles  associated  with  dis- 
eases   of    the    urinary    apparatus    often 


BRIGHT'S  DISEASE.    NON-EXUDATIVE  CHRONIC  NEPHRITIS.     SYMPTOMS. 


611 


disguise   the   latter.     Alapy    (Revue   de 
Th6r.  M6dico-Chir.,  Oct.  15,  '93). 

Twenty-two  cases  of  ulceration  of  the 
intestine  coincident  with  renal  affec- 
tions, and  eight  cases  of  hiemorrhagio 
extravasation  without  ulceration.  Situ- 
ated at  all  points  of  the  intestine,  but 
especially  about  the  ileum,  principal 
characteristic  being  that  they  were  ac- 
companied by  haemorrhage.  Dickinson 
(Brit.  Med.  Jour.,  Jan.   13,  '94). 

Complications   in    the   digestive   tract. 
E.xamination    of    17    cases, — 3    of    large 
waxy  kidneys  and  10  of  secondary  and  4 
of    primary    contracted    kidney,  —  intes- 
tinal   lesions    in    most    of    them,    from 
simple  catarrh  to  diphtheritic  exudation. 
Fischer     (Deutsche    med.-Zeit.,    Aug.    9, 
'94). 
There  is,  as  a  rule,  no  oedema  in  renal 
sclerosis,  and  when  it  does  occur  (as  in 
the  ankles  and  limbs)  it  is  due  to  car- 
diac  dilatation   and  failure.     The   skin 
is  dry,  and  the  jDores  sometimes  appear 
lustrous  with  minute  scales  of  urea.    The 
skin  has  often,  also,  a  cj'anotic  tinge, 
with  a  certain  degree  of  pallor.    Trouble- 
some eczema  and  pruritus  are  often  pres- 
ent, and  muscular  cramps  may  make  the 
patient  still  more  uncomfortable;    the 
latter  occur  at  night  and  especially  in 
the  calves  of  the  legs.    Other  cutaneous 
disorders  may  also  occur. 

1.  There  is  a  bright-red  diffused  rash 
which  appears  chiefly  on  the  trunk,  less 
extensive  on  the  neck,  arms,  and  thighs, 
and  very  seldom  on  the  face,  hands,  or 
feet.  It  is  distinguished  from  the  some- 
what similar  rash  produced  by  natural 
or  artificial  diaphoresis  by  its  locality, 
by  the  absence  of  sudamina,  and  by  its 
appearing  when  no  hot-air  baths  or  other 
means  have  been  used  to  produce  sweat- 
ing and  when  the  skin  is  harsh  and 
dry.  As  it  does  not,  as  a  rule,  either  itch 
or  smart,  and  only  remains  a  few  days. 
Most  often  seen  in  eases  of  chronic  tubal 
nephritis. 

2.  There  is  a  papular  eruption  with 
large,  discrete,  rather  dark-red  pimples 
seated  on  a  dry,  rough,  and  sometimes 
scaly  surface.     This  more  often  seen  on 


the  outer  side  of  the  thighs  and  legs,  the 
shoulders,  and  e,\tensor  surface  of  the 
forearms,  but  it  also  may  affect  the  loins 
and  the  abdomen.  Personally  never  seen 
on  the  face  or  on  the  hands  and  feet. 

3.  Apart  from  the  mere  coincidence  of 
eczema  with  Bright's  disease,  there  may 
be  observed  in  some  cases  a  moist  der- 
matitis resembling  eczema  in  its  aspect, 
but  accompanying  the  arms  or  the  legs, 
without  affecting  the  flexures  of  the 
joints,  the  face  or  the  ears,  without  the 
irritation  commonly  present,  and  with- 
out having  previously  appeared. 

4.  On  two  occasions  a  very  extensive 
and  profuse  dei-matitis  seen,  closely  re- 
sembling the  universal  exfoliative  derma- 
titis of  Wilson,  very  red,  very  scaly, 
occupying  the  scalp,  palms,  soles,  and 
genitals,  as  well  as  the  trunk,  face,  and 
limbs.  It  has  come  on  after  the  symp- 
toms of  Bright's  disease  have  appeared, 
in  cases  of  chronic  interstitial  nephritis, 
with  little  dropsy,  and  cardiovascular 
changes  already  apparent.  P.  H.  Pye- 
Smith  (Brit.  Med.  Jour.,  Nov.  30,  '95). 

Debility  and  emaciation  become  ex- 
treme, with  the  gradual  faiure  of  the 
general  niitrition. 

UiEemia  may  supervene  at  any  time, 
and  may  even  form  the  first  symptom; 
it  may  also  be  sudden  and  severe  in  its 
attack  (acute  uraemia),  or  gradual,  mild, 
and  insidious  (chronic).  These  ursemic 
attacks  may  be  accompanied  by  either 
a  normal  temperature,  or  by  moderate 
fever;  the  temperature  may  even  be  sub- 
normal, in  chronic  ursemia  with  prostra- 
tion, coma,  a  feeble  pulse,  and  delirium. 

Among  the  complications  that  Eiay 
occur  in  the  red,  granular,  and  con- 
tracted kidney  are  the  following:  Pleu- 
ritis,  endocarditis,  pericarditis;  pneu- 
monia, either  lobar  or  lobular;  laryngitis, 
bronchitis,  hepatic  cirrhosis,  gastritis, 
enteritis,  peritonitis,  meningitis,  emphy- 
sema, phthisis,  and  mental  disorders. 

Early  in  the  establishment  of  chronic 
Bright's  disease,  especially  the  intersti- 
tial variety,  the  mind  seems  somewh&t 


612      BRIGHT'S  DISEASE.     NON-EXUDATIVE  CHRONIC  NEPHRITIS.     ETIOLOGY. 


fogged  or  "muddy,"  the  soundness  of 
business  judgment  is  apt  to  be  impaired; 
there  are  irritability,  petulance,  and  de- 
pression often  noted;  the  patient  may 
become  a  little  self-distrustful,  suspi- 
cious, or  somewhat  secretive  about  his 
affairs  or  intentions;  he  is  easily  an- 
noyed by  loud  noises,  is  disinclined  to 
exercise  his  intellect,  apt  to  doze  in  the 
day  and  be  wakeful  at  night,  and  in 
many  ways  indicates  the  approach  to 
the  borders  of  insanity.  Andrew  Clark 
(Brit.  Med.  Jour.,  Feb.  4,  '83). 

Case  of  a  patient  who  suffered  from 
insanity  and  chronic  nephritis.  When- 
ever the  renal  disease  was  exacerbated, 
the  patient's  mental  condition  also  be- 
came worse. 

Case  of  a  lady,  in  whom  the  autopsy 
showed  interstitial  nephritis,  who  passed 
the  last  weeks  of  her  life  in  a  state  of 
acute  delusional  insanity.  Raymond 
(Gaz.  Med.  de  Paris,  Nos.  25  and  26,  '90). 

Similar  case,  except  that  the  patient 
became  cataleptic  and  manifested  bulbar 
phenomena  a  short  while  before  death. 
Brissaud  and  Lorring  (Gaz.  des  Hop., 
Nos.  31  and  32,  '90). 

Important  to  distinguish  those  cases 
where  the  insanity  exists  along  with, 
but  independently  of,  the  renal  condi- 
tion, not  being  influenced  either  in  its 
inception  or  in  its  manifestations  by  the 
nephritis,  and  those  cases  which  are 
•called  into  being  by  the  toxication  from 
the  renal  inadequacy,  or  those  which, 
•existing  perhaps  latently  as  an  heredi- 
itary  predisposition,  are  intensified  by  the 
influence  of  the  disease  of  the  kidneys 
so  as  to  become  manifest.  The  latter 
classes  of  cases  may  be  examined  as  to 
their  mental  condition,  with  a  view  of 
estimating  as  well  the  degree  of  failure 
of  the  renal  function;  while  they  are 
more  yielding,  the  treatment  of  the  un- 
derlying nephritis  modifies  the  sympto- 
matic mental  condition.  Joffroy  (Le 
Bull.  M6d.,  Feb.  4,  '91). 

Case  in  which  alternation  of  coma 
with  maniacal  outbursts  and  with  occa- 
sional delirium  marked  clearly  the  re- 
lationship between  the  ordinary  manifes- 
tations of  uraemia  and  conditions  of 
alienism.  The  patient  eventually  recov- 
ered from  all  active  symptoms.    Remon- 


dino  (Jour,  of  Nerv.  and  Mental  Dis., 
Oct.,  '91). 

Number  of  cases  and  statistics  show- 
ing the  frequency  of  nephritis  in  in- 
sanity. Bondurant  (Jour,  of  Nerv.  and 
Mental  Dis.,  Nov.,  '92). 

Affections  of  the  kidneys  are  very 
common  among  the  insane.  Uraemic 
poisoning  is  one  of  the  most  frequent 
causes  of  insanity.  Alice  Bennett 
(Alienist  and  Neurol.,  Oct.,  '94). 

[We  doubt  very  much  whether  Dr. 
Bennett  finds  many  followers  in  her  con- 
fession of  faith.  We  venture  the  pre- 
diction that,  of  1000  cases  in  ordinary 
life,  as  many  cases  of  kidney  disease  will 
be  found  as  in  the  same  number  of  the 
insane,  if  general  paretics  are  excluded. 
We  have  made  it  a  subject  of  careful 
observation  for  some  years,  and  have 
not  found  the  proportion  of  kidney 
lesions  which  Dr.  Bennett  appears  to 
have  observed.  In  the  few  cases  of 
"grave  delirium"  which  have  come  under 
our  care  this  point  has  been  especially 
examined  with  negative  results,  and  the 
same  may  be  said  in  the  majority  of  in- 
stances of  mental  depression  and  anxiety. 
Bkush,  Assoc.  Ed.,  Dept.  of  Mental  Dis., 
Annual,  '91.] 

Mental  aberration — illusions,  halluci- 
nations, general  confusion,  impairment 
of  memory,  aphasia,  neuralgia,  paral- 
ysis, etc. — connected  with  renal  lesions. 
Bremer   (Med.  News,  Oct.  20,  '94). 

A  large  majority  of  patients  present- 
ing retinal  lesions  die  mthin  a  year 
after  they  are  first  discovered.  Out  of 
419  of  Bell's  cases  he  found  that  72 
per  cent,  were  fatal  at  the  end  of  the 
first  year  and  90  per  cent,  within  two 
years.  Possauer  reports  that  all  men 
applicants  at  his  clinics  were  dead 
within  two  years.  Of  the  women  32 
per  cent,  survived  that  period.  It  seems 
that  among  private  patients  only  59 
per  cent,  of  the  men  died  within  two 
years  and  53  per  cent,  of  the  women. 
Edward  Jackson  (Medical  News,  Feb. 
15,  1902). 

Etiology.  —  Sometimes  the  cause  of 
the  slow,  primary,  diffuse  degeneration, 
atrophy,  and  fibroid  contraction  of  the 
kidneys  is  quite  obscure,  and  in  certain 


BRIGHT'S  DISEASE.     NON-EXUDATIVE  CHRONIC  NEPHRITIS.     ETIOLOGY. 


613 


cases  it  would  seem  to  be  "only  an  an- 
ticipation of  the  gradual  changes  which 
take  place  in  the  organ  in  extreme  old 
age"  (Osier),  —  the  "senile  kidney." 
Heredity  undoubtedly  plays  a  part  in 
the  causation  of  certain  cases,  and  its 
iniiuenee  has  extended  down  through 
the  third  and  fourth  generations. 

Age  and  sex  also  exert  an  influence, 
the  disease  being  more  common  in  males 
than  in  females,  and  usually  beginning 
near  middle  life.  It  is  rarely  manifested 
symptomatically  until  the  fiftieth  or  six- 
tieth year.  A  special  tendency  to  scle- 
rotic degeneration  of  the  arteries,  from 
whatever  injurious  influence,  whether 
chemicotoxic  or  parasitic,  renders  the 
patient  more  prone  to  interstitial  ne- 
phritis, though  prolonged  irritation  by 
such  agents  may  also  cause  the  disease 
in  persons  whose  cellular  nutrition  is 
usually  not  defective.  Alcoholism,  uric 
acid,  and  lead,  giving  rise  to  chronic 
poisoning,  have  all  been  assigned  as 
causes  of  the  disease. 

Chronic  malaria  and  syphilis  also 
probably  exert  a  causative  influence. 

Habitual  overeating  and  overdrinking 
no  doubt  frequently  cause  granular  atro- 
phy and  sclerosis  of  the  organ,  owing  to 
the  imperfect  assimilation  of  the  sub- 
stances ingested  and  the  constant  excre- 
tion of  irritating  products  by  the  kidney 
caused  thereby.  A  wide-spread  cause  of 
the  disease  is  the  continuous  and  even 
moderate  use  of  alcohol  for  many  years; 
especially  is  this  true  in  the  case  of 
spirituous  liquors.  It  is  just  as  probable 
that  the  excessive  use  of  red  meats  in 
the  diet  leads  to  the  production  of  the 
iiric  acid  that  induces  the  renal  condi- 
tion (uricffimia-lithsemia)  by  deranging 
the  hepatic  function  (Murchison). 

Gout  may  also  cause  chronic  Bright's 
disease,  and  is  allied  to  the  above;  this 
occurs  perhaps  more  frequently  in  Eng- 


land than  in  this  country,  where  liths- 

mia    and    nervous    dyspepsia    are    more 

often  seen. 

Striimpell  states  that  severe  articular 

rheumatism    is    sometimes    followed   by 

contracted  kidney. 

Chronic  nephritis  when  met  with  in 
ehloroties  depends  upon  an  arterial 
lesion;  patients  affected  with  the  two 
diseases  are  clearly  descendants  of  gouty 
arteriosclerotic  ancestors.  Lancereaux 
(Bull,  de  I'Acad.  de  Med.  de  Paris,  p. 
727,  '93). 

Appearance  of  gi-eat  quantities  of  urie 
acid  in  the  blood  of  nephritis  not  as 
constant  as  observations  of  Jacobi  might 
lead  one  to  think.  Fodor  (Centralb.  fiir 
klin.  Med.,  Sept.  7,  '95). 

The  absorption  of  toxic  substances 
from  the  intestinal  iract  plays  the  most 
important  role  in  the  etiology  of  chronic 
nephritis.  The  importance  of  this  is 
very  practically  acknowledged  by  the 
range  of  dietetic  treatment  for  the  affec- 
tion. The  morning  purge,  colonic  irriga- 
tion, and  excitation  of  the  intestinal 
functions  generally,  lead  to  prompt 
amelioration  of  the  nephritic  symptoms. 
On  the  otlier  hand,  serious  nephritic  con- 
ditions are  ushered  in  by  intestinal  acci- 
dents. The  first  symptoms  of  uraemia  or 
of  kidney  insufficiency  are  usually  noted 
in  the  gastro-intestinal  tract.  The  coated 
tongue,  the  nausea,  the  pain  in  the  back, 
the  oxaluria,  etc.,  are  all  common  symp- 
toms of  nephritis  and  intestinal  dis- 
turbance. After  the  kidney  function  is- 
lowered  the  liver-cells  degenerate  be- 
cause of  the  presence  of  toxic  sub- 
stance; the  liver  then  fails  to  metab- 
olize substances  that  come  to  it,  and' 
adds  its  own  quota  of  toxic  material 
to  the  blood,  which  still  further  irri- 
tates the  kidney.  The  vicious  circle  of 
influence  thus  formed  continually  de- 
teriorates the  general  condition. 

The  inactive  life  of  many  city  people 
is  undoubtedly  a  cause  for  the  develop- 
ment of  toxic  systemic  products  that 
irritate  the  kidneys.  Almost  invariably 
such  people  overeat,  and  this  adds  to 
the  manufacture  of  toxins.  In  these 
patients  the  urine  is  often  quite  toxio 
when  injected  into  animals.     The  basis 


614      BRIGHT'S  DISEASE.    NON-EXUDATIVE  CHRONIC  NEPHRITIS.     PATHOLOGY. 


of  these  metabolic  disturbances  is  often 
an  atonic  intestinal  catarrh.  This  con- 
dition, however,  is  perhaps  itself  a 
manifestation  of  uraemie  conditions. 
Constipation  is  a  very  uncertain  effect. 
Though  long  continued  in  some  people, 
it  fails  to  produce  any  serious  systemic 
effect,  while  in  others  its  existence  for 
a  comparatively  short  time  produces 
many  and  even  serious  symptoms. 
Coprostasis  provides  in  the  material  de- 
tained in  the  intestinal  tract  a  very 
favorable  cultvire-mediuni  for  micro  oes. 
These  not  only  produce  poisons  them- 
selves, which  are  absorbed  with  serious 
effects,  but  they  also  consume  normal 
food-material  in  the  intestines  and  leave 
only  degradation  products  to  be  taken 
up  for  the  body-nutrition.  These  factors 
are  especially  active  in  the  production 
of  chronic  nephritis,  and  the  realization 
of  this  furnishes  the  best  indications  for 
treatment.  A.  R.  Elliott  (Proceedings 
Amer.  Med.  Assoc;  Medical  News,  June 
21,  1902). 

Anxieties,  worries,  and  the  liigh  nerv- 
ous tension  required  by  modern  business 
activity  and  by  social  life  (the  latter, 
particularly,  in  elderly  ladies)  favor  the 
development  of  chronic  Bright's  disease. 
Associated  with  these  causes  are  usually 
to  be  found  an  overindulgence  in  rich 
foods  and  sedentary  habits. 

The  cold,  moist  climate  of  ISTew  Eng- 
land and  the  Middle  States  seems,  to 
Purdy,  to  predispose  to  contracted  kid- 
ney. Hydronephrosis,  chronic  pyelitis, 
and  chronic  congestion  of  the  kidney 
(of  cardiac  origin,  etc.)  may  cause  a 
chronic  productive  nephritis  without 
exudation,  though  never  the  true  "con- 
tracted and  red-granular"  kidney. 

Bright's  disease  is  not  primarily  a 
kidney  disease,  but  is  really  a  circula- 
tory distvu'bance.  The  brain  and  kid- 
neys, the  end-organs  of  the  circulation, 
suffer  most.  It  may  well  happen  that 
death  comes  on  from  brain-lesion  at  a 
time  when  the  kidneys  are  yet  in  rea- 
sonablv   good   condition.     Details   of   a 


case  in  which,  by  careful  dieting  and 
avoidance  of  extremes  of  temperature 
or  other  hurtful  factors,  the  kidneys 
were  spared,  yet  the  fatal  issiie  came 
through  the  brain.  The  brain  is  a  very 
sensitive  organ,  and  may  show  signs 
early  in  the  case.  The  kidneys  are  in- 
sensitive, and  may  not  react  until  late 
in  the  progress  of  the  arterial  changes. 
The  first  sj'mptoms  of  Bright's  disease 
may  be  those  of  increased  arterial  ten- 
sion. There  may  be,  because  of  this, 
increased  frequency  of  urination  or  oc- 
casional nose-bleed  or  persistent  head- 
ache. A  very  early  symptom  may  be 
functional  gastric  disturbance  from  in- 
creased blood-pressure.  These  gastric 
symptoms  must  not  be  confounded  with 
the  nausea  and  vomiting  of  later  stages 
of  nephritis.  The  prenephritic  condition 
of  Bright's  disease  may  be  detected  in 
the  irregularities  of  the  circulation. 
These  may  give  rise  to  clumsiness  m  the 
use  of  limbs  or  to  actual  paresis  of  one 
or  moi'e  members.  There  may  be  tem- 
porary aphasia,  and  this  symptom  may 
recur  several  times,  passing  off  com- 
pletely in  the  interval.  The  earliest 
symptoms  of  Bright's  disease  if  carefully 
looked  for  will  nearly  always  be  found 
in  the  brain.  L.  Faugeres  Bishop  (Pro- 
ceedings Amer.  Med.  Assoc;  Medical 
News,  June  21,  1902). 

Pathology.  —  The  reduction  in  size 
and  weight  is  about  equal  in  both  organs 
in  genuine  primary  contraction  of  the 
kidneys.  The  two  kidneys  may  together 
weigh  not  over  two  ounces,  and  they  may 
be  only  one-half  or  one-third  the  normal 
size.  They  are  frequently  imbedded  in 
thick,  adipose  tisstie,  and  the  capsule  is 
thick,  opaque,  and  very  adherent;  so 
that,  on  stripping  it  off,  portions  of  the 
renal  cortex  come  away  at  the  same  time. 
The  outer  surface  of  the  organ  is  red, 
irregularly  granular,  or  finely  nodular, 
and  occasionally  small  cysts  are  present. 
The  tissue  is  firm,  dense,  and  resistant 
to  the  knife.  The  cut  surface  shows  a 
thin,  atrophied  cortex,  with  dark-reddish 
streaks   alternating  with   pale   portions. 


BRIGHT'S  DISEASE.    NON-EXUDATIVE  CHRONIC  NEPHRITIS.    PATHOLOGY.       615 


The  pyramids  are  darker  than  the  cortex, 
and  are  also  diminished.  In  the  gouty 
contracted  kidney  they  show  fine  stria- 
tions  of  sodium  urate  or  of  uric  acid, 
or  crystals  representing  uric-acid  infarc- 
tions. The  principal  changes  are  seen 
microscopically  to  be  an  increased  pro- 
duction of  connective  tissue,  especially 
in  the  cortical  substance,  and  a  more 
or  less  proportionate  degeneration  and 
atrophy  of  the  renal  parenchyma.  The 
destruction  of  the  latter  is  due  to  the 
circulation  of  noxious  agents,  but  it  is 
replaced  by  cicatricial  fibrous  tissue 
(Weigert).  This  new  tissue  is  not  uni- 
formly distributed  in  the  cortex,  but 
appears  in  irregular  masses  around  the 
shrunken  glomeruli  or  between  the 
tubules.  In  the  pyramids  the  distri- 
bution is  more  general.  The  glomeruli 
are,  in  many  instances,  very  small  and 
fibrous  in  advanced  cases;  in  the  earlier 
cases  the  cells  of  the  tufts  and  capsules 
are  swelled  and  multiplied  and  a  small- 
celled  infiltration  may  be  seen  around 
the  glomeruli  and  tubules.  This  cellular 
infiltration  later  becomes  fibrillated  and 
ends  in  thickening.  The  changes  in  and 
the  growth  of  the  capillary  and  intra- 
capillary  cells  and  of  those  around 
the  tufts  are  partly  responsible  for  the 
glomerular  atrophy,  as  are  also  the  cap- 
sular thickening  and  hyaline  or  waxy 
degeneration  and  the  thickening  and 
occlusion  of  arterioles.  The  tubules 
show  decided  changes,  some  being  in- 
cluded in  masses  of  connective  tissue, 
with  resiilting  compression-atrophy  and 
even  obliteration  of  the  lumen.  Others 
show  constriction  by  the  intertubular 
connective  tissue,  the  lumen  ekswhere 
thus  being  increased;  this  is  especially 
prominent  in  the  granules  on  the  outer 
surface  of  the  kidney,  and  little  cysts 
may  be  seen  here  and  there  by  the  naked 
eye,  as  the  result  of  damming  back  the 


urine  in  the  tubules  thus  afl:ected.  The 
epithelium  lining  these  tubules  shows 
granular,  fatty,  or  waxy  degeneration, 
and  may  be  either  flattened,  cuboid,  or 
swollen  in  variety.  The  tubes  may  con- 
tain fatty  or  granular  debris  and  tube- 
casts. 

In  a  former  paper  it  was  concluded 
that  an  actual  physical  alteration  of  the 
tissues  is  brought  about  by  the  toxic 
substances  retained  in  the  blood  owing 
to  the  insuificient  action  of  the  kidneys. 
This  alteration  leads  to  oedema,  on  the 
one  hand,  and  to  a  rise  of  arterial  press- 
ure, on  the  other,  due  to  increased  periph- 
eral resistance.  From  this  follows  the 
hypertrophy  of  the  heart. 

This   theoretical   view   now   confirmed 
by  actual  experiment.     Physiological  so- 
dium-chloride solution  was  injected  hypo- 
dermieally  in  cases  of  nephritis  without 
oedema,  and  it  was  found  that  the  arti- 
ficial oedema  thus  produced  was  not  ab- 
sorbed for  from  five  to  ten  days,  while 
if  the  same  were  done  in  non-nephritic 
cases,  even  when  heart  disease  was  pres- 
ent, it  disappeared  in  a  few  hours,  or  in 
three   days   at  the   latest.     This   proves 
that  the   absorptive   power   of  the   sub- 
cutaneous tissue   is   much   restricted   in 
Bright's    disease.     Eeichel    (Centralb.    f. 
inn.  Med.,  Oct.  15,  '98). 
The  growth  of  fibrous  tissue  in  the 
walls  of  the  arteries,  causing  sclerosis, 
forms    an    important    change    in    most 
instances.      The    intima    (endarteritis), 
media,  and  adventitia  are  all  thickened 
by  the  hyperplasia  of  connective-tissue 
elements,  and  the  arteries  and  capillaries 
are,   in   this   way,   mostly   occluded   by 
the  obliterating  endarteritis  or  by  their 
conversion  into  connective  tissue.    "VVaxy 
or   hyaline    degeneration   is   also    seen. 
These  changes  may  sometimes  form  the 
primary  condition  that  leads  to  granular 
and  contracted  kidneys,  and  may  repre- 
sent the  renal  effects  of  a  general  arterio- 
sclerosis. 

In  a  case  of  interstitial  nephritis  ter- 
minating in  cerebral  atrophy,  aneurismal 


616     BRIGHT'S  DISEASE.    NON-EXUDATIVE  CHRONIC  NEPHRITIS.    TREATMENT. 


dilatations  of  the  cerebral  arteries  ob- 
served, besides  an  hsemorrhagie  area  filled 
with  fluid  blood,  which  might  have  been 
taken  for  an  aneurism,  which  was  in 
reality  due  to  rupture  of  the  artery  and 
successive  hsemorrhages  into  the  cerebral 
substances.  Israel  (Berliner  klin.  Woch., 
Jan.  29,  '94). 

The  urea  introduced  into  the  circula- 
tion leads  to  a  constriction  of  the  vessels 
of  the  periphery.  Retention  of  urea 
causes  elevation  of  vascular  pressure 
and  is  the  cause  of  cardiac  hypertrophy 
in  patients  with  Bright's  disease.  Chia- 
ruttini  (Inter,  klin.  Eund.,  Feb.  18,  '94). 

Cardiac  hypertrophy  is  an  almost  con- 
stant attendant  upon  chronic,  non-exu- 
dative, productive  nephritis,  and  its  de- 
gree depends  upon  the  extent  of  the 
renal,  and  also  of  the  general  arterial, 
degeneration  and  sclerosis.  Cor  iovinum 
has  been  applied  to  the  organ,  on  ac- 
count of  its  extreme  size  in  this  affection. 
The  left  ventricle  only  is  hypertrophied 
in  moderate  enlargements. 

Among  the  many  complications  of 
chronic  Bright's  disease  may  be  men- 
tioned cirrhosis  of  the  liver,  pulmo- 
nary emphysema,  cerebral  hemorrhage, 
chronic  endocarditis,  endarteritis,  peri- 
carditis, and  bronchitis. 

Prognosis.  —  Chronic  interstitial  ne- 
phritis varies  in  duration,  and  in  uncom- 
plicated cases  it  may  last  for  five,  ten, 
twentj^,  or  possibly  thirty  years.  The 
duration  may,  however,  be  very  much 
shortened  by  complications  or  intercur- 
rent affections,  or  the  condition  may  not 
be  appreciated,  as  often  occurs,  when 
the  post-mortem  examination  discovers 
the  characteristic  kidneys  in  one  who 
had  no  symptoms  of  renal  disease  dur- 
ing life  and  whose  death  was  directly  due 
to  some  intercurrent  affection.  Life  is 
destroyed  sooner  or  later  by  this  dis- 
ease, unless  the  patient  first  dies  from 
some  intercurrent  malady.  Irreparable 
damage  to  the  orafans  results  from  the 


gradual  destruction  of  the  renal  paren- 
chyma and  its  replacement  by  scar-tissue. 
The  fact,  however,  that  the  process  is 
slow  and  its  duration,  therefore,  long 
allows  a  preservation  of  life  for  many 
years,  and  often  with  comparative  com- 
fort. The  prognosis  depends  much  upon 
the  general  condition  of  the  patient, 
the  cardiovascular  system,  and  upon  the 
presence  of  uraemia  and  inflammatory 
complications.  A  not  far  distant  end  is 
indicated  by  cardiac  dilatation  and  in- 
sufficiency. Haemorrhages,  diarrhoea, 
persistent  vomiting,  nephritic  retinitis, 
coma,  and  delirium  render  the  prognosis 
exceedingly  grave.  Convulsive  and  apo- 
plectic seizures  are  often  fatal. 

Haematuria,  a  frequent  accompaniment 
of  nephritis,  is  of  grave  import.  Case  of 
Bright's  disease  kept  in  comparatively 
good  health  by  strict  attention  to  diet 
and  climate  several  years.  As  soon  as 
haematuria  appeared,  however,  he  rapidly 
lost  ground  and  died.  Any  appeai-ance 
of  blood,  hoAvever  slight,  in  chronic 
nephritis  denotes  an  early  demise.  Dieu- 
lafoy  (Jour,  de  Mgd.,  May  10,  '97). 

Treatment. — A  strict  hygienic  regime 
following  an  early  appreciation"  of  the 
disease  will,  to  a  considerable  degree, 
prevent  the  advance  of  the  cirrhotic 
process.  ISToxious  substances  that  have 
an  etiological  influence  must  be  removed 
as  thoroughly  as  possible  and  avoided. 
Uric-acid  formation  must  be  reduced  by 
dietetic  supervision,  alcohol  must  be  in- 
terdicted, and  lead — when  the  causative 
factor — must  be  prevented  from  further 
poisoning  the  system  by  a  change  of 
occupation.  The  heart  and  blood-vessels 
are  also  preserved  by  the  diminution  of 
these  irritants.  The  hygienic  treatment 
embraces  a  regulation  of  all  the  habits 
of  the  body  and  the  mode  of  living.  The 
malady  is  incurable;  therefore  the  pa- 
tient himself  must  be  treated,  and  not 
the   malady.      A   suitable   dietary  must 


BRIGHT'S  DISEASE.    NON-EXUDATIVE  CHRONIC  NEPHRITIS.    TREATMENT.      617 


be  formulated  for  each  individual,  and 
Saundby's  rule  furnishes  a  good  work- 
ing principle:  "Eat  very  sparingly  of 
butchers'  meat;  avoid  malt  liquors, 
spirits,  and  strong  wines."  An  absolute 
milk  diet  may  be  necessary  for  short 
periods  in  the  presence  of  gastric  irri- 
tability, but  undue  weakness  will  be  the 
result  of  a  continued  restriction  to  milk 
alone. 

Authors  are  by  no  means  unanimous 
as  to  the  best  diet  for  patients  with 
chronic  Bright's  disease.  All  the  a 
priori  reasons  urged  in  favor  of  milk  or 
any  other  particular  diet  were  fallacious. 
The  only  way  to  attack  the  problem  is 
carefully  to  observe  the  condition  of  the 
urine  and  the  condition  of  the  patient 
upon  different  diets. 

1.  Quantity  of  urine.  Usually  more 
urine  was  secreted  upon  farinaceous  or 
milk  diets  than  upon  full  diet. 

2.  Specific  gravity.  The  diet  had  no 
certain  influence  on  this,  but,  on  the 
whole,  it  was  lower  on  milk  and  fari- 
naceous diets  than  on  full  diet. 

3.  The  quantity  of  albumin  passed. 
The  figures  showed  that  nearly  always 
the  albumin  passed  was  more  upon  milk 
diet  than  upon  farinaceous,  and  less 
upon  full  diet  than  upon  either  milk  or 
farinaceous.  Patients  always  best  avoided 
loss  of  albumin  by  a  full  diet. 

4.  The  quantity  of  urea  passed.  The 
influence  of  diet  upon  this  was  most  un- 
certain; often  less  urea  was  passed  upon 
full  diet  than  upon  farinaceous,  and  less 
upon  farinaceous  than  upon  milk.  Some 
times  the  reverse  was  true. 

5.  General  condition  of  the  patient. 
The  cases  distinctly  showed  that  a  full 
diet  was  not  more  liable  to  lead  to 
uraemia  than  any  other;  in  fact,  in  one 
patient  full  diet  appeared  to  ^Ya^d  oflF 
ursemia,  and  the  patient  ultimately  re- 
covered. The  patients  always  felt  and 
seemed  much  better  and  stronger  on  full 
diet,  or  on  farinaceous  diet  with  meat 
or  eggs  added,  than  on  milk  or  farina- 
ceous only.  Hale  White  (Brit.  Med. 
Jour.,  Apr.  29,  '93). 

Loss  of  albumin  main  point  to  be  coun- 
teracted.    Loss  not  made  up  by  increase 


of  proteid  food.     Rich  proteid  diet  may 
lead  to  retention  of  nitrogenous  e.xtract- 
ives.    Hence,  6  ounces  of  meat,  13  ounces 
of  bread,  liberal  allowance  of  vegetables 
and   fruit,   1  Vs   ounces  sugar,  5   ounces 
fat  a  typical  diet  in  chronic  albuminuria. 
Milk  mainly  useful  in  acute  cases  when 
loss  of  appetite,  or  in  addition  to  above 
mixed  diet.    Hirschfeld  (Zeit.  fiir  Krank- 
enpflege,   May,   '95). 
A  light,  nourishing  diet  is,  therefore, 
advisable.     Lean  meat  may  be  allowed 
once  daily  in  favorable  cases,  and  vege- 
tables,  greens,   fruits,    and   light,   well- 
cooked,  farinaceous  articles  may  also  be 
partaken  of.    Tea,  coffee,  and  cocoa  may 
be  drunk.    The  use  of  the  natural  min- 
eral waters  aids  in  the  renal  circulation 
and  keeps  the  kidneys  flushed.     As  a 
rule,  a  mixed  diet  will  be  advantageous. 
The  carbohydrate  and  nitrogenous  ele- 
ments (sugars  and  starches)  should  be 
used  in  moderate  amounts,  but  fruits 
and  pure  fats  are  to  be  strongly  recom- 
mended. 

Von  Noorden  announces  that  in  cases 
of  contracted  kidney  and  the  early  stage 
of  heart-weakness  the  elimination  of 
the  products  of  metabolism  is  not  in- 
fluenced to  any  extent  by  a  reduction 
of  the  amount  of  fluid  taken  daily. 
Albumin  does  not  seem  to  be  materially 
changed  either  by  an  increase  or  de- 
crease in  the  amount  of  liquid  ingested. 
Moreover,  in  Bright's  disease,  when  the 
heart  is  failing,  a  diminution  of  the 
quantity  of  water  proves  beneflcial. 
The  reduction  of  the  quantity  of  liquid 
is  advised  in  the  early  stages.  He  has 
also  noticed  that  after  the  ingestion  of 
a  large  quantity  of  water  in  contracted 
kidney  there  is  enlargement  and  weaken- 
ing of  the  heart.  In  the  advanced 
stages,  with  a  corresponding  degree  of 
arteriosclerosis  with  hypertrophy  of  the 
heart,  restriction  of  liquid  is  impera- 
tive. The  average  quantity  of  liquor 
advised  is  2  pints.  Professor  Ewald 
confirms  von   Noorden. 

The  bath  treatment  was  based  on  the 
assumption  that  the  action  of  the  skin 
had  a  certain  connection  with  functions 


618     BRIGHT'S  DISEASE.    NON-EXUDATIVE  CHRONIC  NEPHRITIS.    TREATMENT. 


of  the  kidneys,  and  that  by  stimulating 
the  former  a  disorder  of  the  kidneys 
might  be  benefited. 

J.  M.  Groedel  (Practitioner,  Dec., 
1901)  has  never  seen  any  curative  re- 
sults from  the  drinking  of  waters.  His 
experience  is  that  the  bath  treatment 
in  eases  of  parenchymatous  nephritis 
is  contra-indicated.  He  divides  cases  of 
contracted  kidneys  into  two  groups.  In 
the  first  group  are  those  in  whom  the 
circulatory  system  is  not  greatly  dis- 
turbed. The  second  group  consists  of 
those  who  show  an  advanced  degree  of 
insuflRcieney  of  the  heart,  which  is  more 
or  less  distinctly  dilated.  In  the  first 
group  of  cases  the  Nauheim  baths  are 
suitable,  but  in  the  second  group  baths 
are  contra-indicated.  It  has  been  said 
that  carbonic-acid  saline  baths  always 
increase  the  blood-pressure,  but  this  is 
not  the  fact,  and  it  has  been  proved  that 
in  cases  of  arteriosclerosis  we  are  able  to 
regulate  the  baths  in  such  a  way  as 
not  to  increase  the  blood-pressure,  but 
rather  to  reduce  it.  If  this  is  the  case, 
these  baths  should  also  be  beneficial 
in  contracted  kidney.  The  baths  of 
Nauheim  have  the  effect  of  reducing 
the  blood-pressure  for  a  longer  period 
than  the  artificial  baths.  The  more 
carbonic  acid  the  bath  contains,  the 
more  the  temperature  may  be  lowered, 
but  not  below  90°  F.  The  baths  seem 
to  dilate  the  peripheral  vessels,  a  con- 
dition brought  about  by  the  irritation 
of  the  gas  and  .  the  reduction  of  the 
blood-pressure;  they  lighten  the  work 
of  the  heart  and  lead  to  a  saving  of 
that  organ,  which  gives  it  a  chance  of 
recovering  strength,  and  this  is  still 
further  promoted  by  the  direct  stimu- 
lating and  tonic  effect  of  these  baths. 
The  increase  in  the  diuresis  is  ascribed 
to  the  strengthening  of  the  heart. 
Editorial  (Phila.  Med.  Jour.,  Aug.  23, 
1902). 

Persons  that  take  considerable  exer- 
cise may  have  considerably  more  food 
than  those  who  are  stout  or  who  lead 
sedentary  lives.  Gastric  disorders  re- 
quire a  liquid  diet  until  the  digestion  is 
restored,   or  the  elimination  of  all  but 


the  soft  and  bland  foods.  All  extremes 
of  activity  (bodily,  mental,  and  emo- 
tional) are  to  be  avoided. 

After  violent  muscular  effort,  there  is 
an  increase  in  the  quantity  of  leucocytes 
and  epithelial  cells  normally  found  in 
urinary  sediment,  and  likewise  the 
apparition  of  cylinder-casts.  Penzolt 
(Munchener  med.  Woch.,  Oct.  17,  '93). 

Physical  exercise  should  be  moderate 
and  regular,  and,  if  the  climate  be  warm 
and  dry,  it  should  be  taken  in  the  open 
air.  The  patient  should  never  be  sub- 
jected to  the  vicissitudes  of  worry,  anx- 
iety, or  to  the  tension  of  competition. 
Indulgences  of  whatever  nature,  if  they 
tend  to  unbalance  self-control  or  disturb 
the  equanimity  of  the  patient,  must  be 
strictly  prohibited. 

Often  life  may  be  prolonged  by  a 
change  of  residence  to  a  warm,  dry,  and 
mild  climate,  since  the  variability  and 
humidity  of  temperate  climates,  particu- 
larly during  the  winter  season,  tend  to 
aggravate  the  disease.  A  sea-voyage  or 
a  sojourn  at  some  southern  European  re- 
sort may  be  very  beneficial. 

Medicinal  treatment  is  employed  for 
the  following  indications:  The  bowels 
should  be  kept  free  by  the  assistance  of 
laxatives  or  by  laxative  alkaline  mineral 
waters.  Papoid,  peptenzyme,  and  other 
digestants,  with  bitter  tonics,  are  useful 
in  cases  of  furred  tongue  and  indigestion. 
Acids  or  alkalies,  according  to  their  spe- 
cial indications,  may  also  be  used  simul- 
taneously. 

High  vascular  tension  is  to  be  met  by 
the  cautious  use  of  nitroglycerin  in  grad- 
ually increasing  doses,  beginning  with  1 
minim  three  or  four  times  daily,  until  all 
danger  of  rapture  of  the  vessels  is  over. 

Nitroglycerin  for  a  considerable  length 
of  time,  so  proportioning  the  dose  that 
the  intervals  shall  be  comparatively 
short, — never  less  than  four  times  daily. 


BRIGHT'S  DISEASE.    NON-EXUDATIVE  CHRONIC  NEPHRITIS.    TREATMENT.      G19 


— and  the  amount  never  more  than  that 
just  necessary  to  cause  the  slightest  feel- 
ing of  fullness  in  the  head  or  to  slightly 
quicken  the  pulse.  In  this  way  a  re- 
markable tolerance  of  the  drug  is  ob- 
tained. Stewart  (Ther.  Gaz.,  Sept.  15, 
'93). 

Among  the  first  indications  which  sug- 
gest themselves  considering  the  cardio- 
vascular conditions  resulting  from  renal 
disease  is  immediate  and  free  venesection 
on  the  occurrence  of  ursemic  convulsions. 
Sixteen  or  twenty  ounces  of  blood  should 
be  taken  at  once,  followed  by  a  calomel 
purge.  If  a  single  withdrawal  of  blood 
does  not  stop  the  convulsions  it  may 
be  repeated,  and  recurrent  ursemic  con- 
vulsions may  be  met  bj^  further  vene- 
section. In  acute  tubular  nephritis 
bleeding  on  account  of  convulsions  may 
be  followed  by  immediate  and  remark- 
able improvement. 

A  further  indication  for  treatment 
may  be  deduced  from  the  fact  that  the 
damage  to  the  vessels  and  heart  through 
which  much  of  the  suffering  attending 
renal  disease  is  brought  about,  and  by 
which  life  is  shortened,  is  due  to  high 
arterial  tension.  The  reduction  of  the 
intravascular  pressure  ought  to  be  an 
object  continually  held  in  view.  For 
this  purpose  the  vascular  relaxants  have 
been  tried:  nitroglycerin,  the  nitrites, 
and  the  tetranitrate  of  erythrol.  Un- 
fortunately the  effect  of  these  sub- 
stances is  very  fugitive ;  but  the  last 
named,  which  is  slower  and  more  per- 
sistent in  its  action,  may  sometimes  be 
given  with  advantage.  The  best  means 
personally  known  of  exercising  a  definite 
influence  on  unduly  high  intra-arterial 
pressure  is  through  mercurial  aperients. 
A  dose  of  calomel,  3  to  5  grains,  will 
often  avert  impending  convulsions  or 
prevent  their  recurrence:  will  relieve 
the  headache,  stupor,  and  twitchings : 
and  may  prevent  uraemic  paroxysmal 
dyspnoea  in  advanced  kidney  disease. 
So  also  a  single  grain  of  pilula  hy- 
drargyri  or  hydrargyri  cum  creta,  with 
rhubarb  or  colocynth  and  hyoscyamus, 
once,  twice,  or  three  times  a  week,  ac- 
cording to  the  degree  of  tension  in  the 
pulse,  exercises  a  favorable  influence 
in   the  earlv   stages  of  chronic   Bright's 


disease,  both  on  the  sjTnptoms  and  on 
the  course  of  the  disease.  W.  H.  Broad- 
bent   (Practitioner,  Nov.,  1901). 

The  other  extreme,  of  a  very  low  ten- 
sion that  induces  dropsy,  and  compli- 
cations, usually  ursemic  (convulsions, 
dyspnoea,  and  headache)  also  call  for 
therapeutic  assistance.  Headache,  ver- 
tigo, and  the  so-called  renal  asthma 
(dyspncea)  are  also  often  relieved  by 
nitroglycerin. 

Morphine  hypodermically  employed  is 
of  conspicuous  benefit  in  the  shortness  of 
breath  of  uraemia.  Ursemic  asthma  yields 
promptly  to  hypodermic  injections  of 
morphine.  On  the  other  hand,  persistent 
distress  of  breathing  may  be  due  to 
dropsy,  and  such  a  condition  is  not  im- 
proved by  the  use  of  morphine.  The 
headache  and  sleeplessness  occurring  in 
ursemic  patients  can  generally  be  re- 
moved by  the  hypodermic  injection  of 
morphine.  Sydney  Ringer  (Jour,  of 
Amer.  Med.  Assoc,  Oct.  8,  '98). 

Low  tension,  with  scanty  albuminous 
urine,  oedema,  and  signs  of  dilatation, 
requires  heart-tonics  and  stimulants,  in 
conjunction  with  purgatives.  Digitalis 
is  effective,  and  especially  in  infusion, 
combined  with  strychnine  nitrate  or 
with  caffeine  citrate.  The  dropsy  calls 
for  calomel  and  the  salines. 

Uremic  symptoms  are  to  be  managed, 
as  in  acute  Bright's  disease,  by  means  of 
free  catharsis  and  profuse  sweating,  and 
occasionally  by  phlebotomy.  In  convul- 
sions, severe  headache,  or  dyspnoea,  in- 
halations of  amyl-nitrite  or  chloroform, 
or  the  h3'podermic  injection  of  morphine, 
Ve  grain,  may  be  tried.  When  there  is 
a  probable  malarial  or  syphilitic  origin, 
contracted  kidney  may  be  benefited  by 
the  use  of  arsenic  and  the  iodides,  re- 
spectively. No  medicaments,  however, 
can  ever  transform  the  connective-tissue 
cells  into  secreting  kidney-cells  or  re- 
store the  destroyed  renal  parenchyma. 


630       BRIGHT'S  DISEASE.     NON-EXUDATIVE  CHRONIC  NEPHRITIS.     TREATMENT. 


To  analyze  thoroughly  the  results  of 
treatment  in  Bright's  disease  one  must 
have  a  clear  conception  of  the  histology 
and  physiological  functions  of  the  kid- 
ney. Its  complex  pathology  must  be 
clearly  understood.  All  the  etiological 
factors  must  he  given  full  consideration. 
The  etiological  factors  are  numerous 
and  very  complicating  in  their  action. 
Only  one,  it  any,  of  these  can  be  reached 
by  surgical  intervention.  Most  of  the 
etiological  factors  can  be  modified  or 
removed  by  well-directed  dietetics  and 
therapeutics.  Histologically  speaking, 
Bright's  disease  can  be  cured.  Phys- 
iologically speaking,  the  etiological  fac- 
tors can  be  modified,  and  often  removed, 
the  symptoms  held  in  abeyance,  while 
the  renal  glands  perform  their  functions 
normally.  Bright's  disease  is  by  nature 
an  oscillatory  malady,  accompanied 
with  frequent  remissions  and  exacerba- 
tions. Remissions  must  not  be  mistaken 
for  cures.  Rational  dietetics  and  thera- 
peutics offer  the  largest  possibility  for 
a  complete  physiological  cure.  A  well- 
regulated  mixed  diet,  especially  if  com- 
posed largely  of  the  animal  class,  when 
it  can  be  tolerated,  yields  the  best  re- 
sults. All  therapeutics  to  be  rational 
must  be  directed,  not  at  the  pathological 
lesion  per  se,  but  toward  establishing 
a  more  perfect  digestion  and  metabolism 
and  a  decrease  in  the  work  imposed 
upon  the  renal  glands.  W.  H.  Porter 
(Medical  Record,  Sept.  27,  1902). 

The  surgical  treatment  of  Bright's  dis- 
ease seems  to  afford  considerable  hope  as 
a  source  of  relief  and,  in  some  cases,  of 
cure.  "During  the  past  year,"  says  an 
editorial  writer  in  the  Journal  of  the 
American  Medical  Association,  ISTov.  15, 
1902,  "there  has  been  a  great  deal  of  in- 
terest in  this  subject,  particularly  since 
the  appearance  of  Edebohls's  paper 
(Med.  Eecord,  Dec.  21,  1901),  in  which 
he  claimed  eight  complete  recoveries 
from  various  forms  of  chronic  Bright's 
disease  at  least  one  year  after  decortica- 
tion of  the  kidney.  After  report  of  such 
brilliant  results  several  operators  under- 
took the  procedure,  but  with  less  satis- 


factory results  than  Edebohls  reported.' 
It  seems  certain,  however,  that  operative 
measures  relieve  or  cure  certain  cases  of 
nephritis,  and  it  is  a  highly-important 
question  to  determine  just  what  classes 
of  cases  are  suited  for  intervention. 

"From  a  careful  study  of  a  series  of  17 
cases  which  he  has  operated  on  for  vari- 
ous forms  of  chronic  nephritis,  Kovsing, 
Professor  of  Surgery  in  the  University  of 
Copenhagen,  attempts  to  formulate  some 
rules  as  to  the  proper  treatment  in  such 
cases.  He  divides  the  cases  into  aseptic 
and  infectious  nephritis.  In  tlie  aseptic 
cases  he  found  that  diffuse  parenchy- 
matous nephritis  was  not  influenced  by 
operation.  A  case  which  he  classed  as 
chronic  glomerulonephritis  recovered  af- 
ter operation,  he  believes,  more  from 
rest  in  bed  than  from  any  favorable  re- 
sttlt  from  the  operation.  In  diffuse  hsem- 
orrhagic  nephritis  tliere  is  much  danger 
in  operating  and  the  results  are  not  sat- 
isfactory. In  four  cases  of  interstitial 
nephritis  and  perinephritis  fibrosa  oc- 
curring with  uric-acid  and  oxalic-acid 
diatheses  his  results  were  satisfactory. 
Operation  is  frequently  undertaken  with 
a  diagnosis  of  stone  in  the  kidney  in  such 
cases  and  gives  relief  without  any  stone 
being  found.  The  severe  pains  which 
are  present  in  these  conditions  he  be- 
lieves indicate  operation.  Pain  always 
indicates  tension  within  the  kidney  cap- 
sule, it  does  not  matter  what  form  of 
nephritis  exists.  But  the  most  impor- 
tant group  of  cases  is  that  caused  by 
some  form  of  infection.  Eight  of  his 
cases  were  of  this  character  and  the  con- 
dition was  only  discovered  after  most 
painstaking  examination.  Urine  ob- 
tained under  aseptic  precautions  should 
be  accurately  examined  chemically,  mi- 
croscopically, and  bacteriologically,  in 
every  case,  whether  we  suspect  that  we 
have  to  deal  with  an  infection  or  not. 


BRIGHT'S  DISEASE.     NON-EXUDATIVE  CHRONIC  NEPHRITIS.     TREATMENT.      G21 


In  case  pathological  constituents  are 
I'onnd,  cystoscopy  and  catheterization  of 
the  ureters  should  be  employed.  In  his 
cases  KoTsing  found  infections  of  the 
urine  from  the  staphylococcus  aureus, 
staphylococcus  albus,  streptococcus  py- 
ogenes, and  bacterium  coli.  Tlie  entire 
clinical  picture  did  not  differ  in  these 
cases  from  that  in  the  aseptic  forms  of 
nephritis.  Neither  was  there  any  differ- 
ence in  the  chemical  constituents  of  the 
urine  or  of  the  appearance  of  the  kidney 
when  it  was  exposed.  The  results  of  op- 
eration in  these  cases  were  very  much 
more  satisfactory,  however,  than  in  asep- 
tic cases,  and  Eovsing  believes  that  his 
cases  show  definitely  that  unilateral 
chronic  nephritis  may  be  of  infectious 
origin;  that  it  may  affect  a  greater  or 
smaller  part  of  the  kidney,  or  that  we 
may  have  a  double  partial  infectious 
nephritis.  Stripping  off  the  kidney  cap- 
sule, which  gives  such  favorable  results 
in  eases  of  aseptic  interstitial  nephritis 
with  perinephritis  and  severe  pain,  also 
has  a  favorable  influence  on  inflamma- 
tory processes.  In  hfemorrhagic  cases  he 
believes  that  splitting  the  kidney  will, 
give  favorable  results  in  the  milder  in- 
fections, such  as  by  the  bacterium  coli, 
but  it  is  dangerous  in  the  more  virulent 
infections.  Eesection  of  the  diseased 
part  in  case  of  local  infectious  nephritis 
which  entirely  resembled  chronic  aseptic 
nephritis  led  to  cure  in  two  of  his  cases. 
"Further  investigation  is  needed  to 
prove  the  value  of  Eovsing's  suggestions. 
Up  to  this  time  infection  with  ordinary 
pyogenic  bacteria  has  not  been  consid- 
ered such  an  important  etiological  factor 
in  cases  of  chronic  nephritis,  though  it 
might  have  been  suspected  that  the  cases 
following  scarlet  fever,  erysipelas,  and 
other  forms  of  infectious  disease  were  of 
this  character.  The  careful  study  of  this 
class  of  cases  which  Eovsing  suggests,  if 


carried  out  by  competent  observer.?, 
could  not  fail  to  give  important  results. 
If  further  study  of  such  cases  proves 
that  we  can  find  such  definite  indications 
for  operation  as  are  above  suggested  a 
great  advance  has  been  made  and  un- 
doubtedly many  lives  will  be  saved.  The 
skepticism  of  many  surgeons  as  to  the 
advisability  of  operating  in  every  case 
of  this  kind  seems  warranted  from  our 
present  knowledge,  and,  until  definite 
grounds  have  been  shown  from  more 
careful  study  of  large  series  of  cases  by 
competent  men,  routine  operation  for 
chronic  nephritis  in  any  case  cannot  be 
considered  an  established  surgical  pro- 
cedure." 

By  persevering  effort  the  author  has 
been  enabled  to  see  or  get  word  from 
all  tlie  patients  operated  on  by  him. 
so  that  he  could  present  the  status  up 
to  date.  The  first  renal  decapsulation 
ever  performed  for  the  relief  of  chronic 
Bright's  disease  was  done  by  him  on 
June  10,  1892,  and  the  patient  was 
permanently  cured.  This  case,  together 
with  reports  of  the  five  preliminary 
operations  which  led  up  to  this  pro- 
cedure, was  published  in  the  Medical 
News  of  April  2,  1898.  Subsequent 
papers  giving  reports  of  other  cases  of 
his  ovra  and  a  resume  of  the  work  of 
other  surgeons  in  this  field  were  pub- 
lished in  the  Medical  Record  of  May 
4  and  December  21,  1901,  and  of  April 
26,  1902.  From  1892  to  1901,  inclusive, 
the  writer  personally  operated  on  19 
cases,  and  during  the  year  1902  on  32 
eases.  Of  this  total  of  51  cases,  29 
were  in  males  and  22  in  females,  and 
the  average  age  was  34  years.  In  32 
eases  the  Bright's  disease  was  far  ad- 
vanced. In  41  of  the  oases  the  period 
which  had  elapsed  between  the  first 
recognition  of  the  disease  and  the  opera- 
tion varied  from  1  month  to  19  years. 
The  general  average  of  this  period  was 

3  '/s  years,  and  in  32  cases  it  was  fully 

4  years.  Nearly  all  the  oases  were  at- 
tended by  cardiac  or  other  complica- 
tions.     Of    the    51    cases,    29    were    of 


G22 


BEIGHT'S  DISEASE. 


BROillDE  OF  ETHYL. 


chronic  interstitial  nephritis,  and  in  all 
but  9  only  one  kidney  was  operated 
on;  14  were  of  diffuse  nephritis  and  8 
of  parenchymatous  nephritis.  If  only 
one  kidney  was  affected  by  Bright's 
disease,  he  said,  the  patient  suffered 
very  little,  and  the  condition  might  be 
discovered  only  accidentally. 

The  chances  of  success  for  the  opera- 
tion are  enhanced  by  the  patient's  re- 
maining in  bed  for  a  week  previous  to 
it.  This  gives  the  heart  a  rest,  if  car- 
diac complications  are  present,  and 
affords  the  best  facilities  for  any  pre- 
liminary treatment  that  may  be  re- 
quired, as  well  as  for  systematic  in- 
vestigation 01  the  quantity  and  condi- 
tion of  the  urine.  There  are  three  con- 
ditions the  presence  or  absence  of  which 
affect  the  facility  with  which  the  opera- 
tion may  be  performed:  1.  Great  length 
and  obliquity  of  the  twelfth  rib.  This 
difficulty  must  be  overcome  by  posture 
and  a  modification  of  the  incision.  2. 
Obliquity  or  firm  appearance  of  the  kid- 
ney. When  there  is  firm  fixation  it  is 
generally  necessary  to  incise  the  capsule 
at  any  point  that  can  be  reached.  For 
separating  the  capsule  the  rubber-cov- 
ered index  finger  is  the  best  instrument. 
3.  The  firm  or  more  or  less  weak  at- 
tachment of  the  capsule.  Great  caution 
and  gentleness  should  characterize  all 
attempts  at  decapsulation.  In  this 
operation  there  is  often  considerable 
danger  of  destroying  some  of  the  al- 
ready diminished  working  tissue  of  the 
kidnej',  and  it  should  never  be  per- 
formed except  by  surgeons  who  are 
alreadj'  more  or  less  familiar  with  renal 
surgerj'  in  general.  The  danger  is 
greater  from  the  condition  present  than 
from  the  operation  itself.  The  pro- 
cedure, however,  should  not  be  too  pro- 
longed; so  that  one  hour  should  be  the 
limit  for  the  decapsulation  of  two  kid- 
neys. The  writer  has  often  found  half 
an  hour  sufficient  for  operating  on  both 
organs.  A  "team  operation"  has  been 
proposed,  with  two  surgeons  each  work- 
ing on  a  kidney,  but  this  would  hardly 
be  feasible,  as  two  operators,  each  with 
his  necessary  assistants,  would  inevi- 
tably interfere  with  the  prompt  accom- 
plishment of  each  other's  work.  An- 
other expedient  suggested  is  that  only 


one  kidney  should  be  decapsulated  at 
a  time ;  but  this  too,  is  to  be  deprecated, 
as  the  time  that  the  patient  would  be 
rmder  an  antesthetic  for  two  separate 
operations  would  necessarily  be  longer 
than  for  operating  upon  both  kidneys 
during  one  period  of  ansesthesia.  George 
H.  Edebohls  (Medical  News,  March  7, 
1903). 

James  M.  Anders, 

Philadelphia. 

BROMIDE  OF  ETHYL.— Bromide  of 
ethyl,  or  hydrobromic  ether,  is  an  anses- 
thetic  prepared  by  combining  bromine 
with  alcohol  in  the  presence  of  phos- 
phorus. It  was  discovered  by  Serullas, 
a  French  chemist,  early  in  this  century. 
It  is  an  extremely  volatile  and  colorless 
liquid,  sweetish  to  the  taste,  and  pos- 
sessing an  alliaceous  odor.  It  presents 
the  advantage  over  ether  in  not  being 
inflammable.  It  is  quickly  eliminated 
from  the  system,  and  its  after-effects  are 
slight.  Another  preparation — bromide 
of  ethylene — is  frequently  dispensed  in- 
stead of  the  bromide  of  ethyl;  it  causes 
nausea  when  inhaled,  and  in  no  way  pos- 
sesses the  qualities  of  the  latter.  Bro- 
mide of  ethyl  is,  however,  frequently 
found  impure  in  the  shops,  and  to  this 
cause  are  due  many  of  the  untoward  re- 
sults met  with. 

Dose. — Bromide  of  ethyl  cannot  be 
used  for  prolonged  operations,  owing  to 
its  high  volatility.  The  dose,  which 
varies  with  the  age  of  the  patient,  should 
not  exceed  6  drachms.  The  administra- 
tion of  bromide  of  ethyl  should  not  be 
prolonged  beyond  two  minutes. 

The  operation  may  usually  be  begun 
twenty  seconds  after  the  first  inhalation. 

Physiological  Action  and  Untoward 
Eifects. — Bromide  of  ethyl  causes  death 
by  arresting  the  heart's  action,  and  the 
cases  should  be  watched  as  if  chloroform 
were  being  administered, — respiration 
and  pulse  simultaneously.    The  prelimi- 


BROMINE  AND  ITS  DERIVATIVES. 


623 


nary  preparations  for  its  administration 
are  tlie  same,  and  the  recumbent  posi- 
tion obligatory  under  all  circumstances. 
Arrest  of  the  heart  may  be  caused,  how- 
ever, through  vasomotor  influence  origi- 
nating in  an  intoxication  by  compounds 
formed  in  the  system. 

Therapeutics. — Bromide  of  ethyl — as 
it  causes  muscular  rigidity — should  not 
be  used  in  operations  in  which  relaxa- 
tion of  the  muscles  would  be  of  assist- 
ance. It  also  increases  the  chances  of 
haemorrhage. 

BEOMINE  AND  ITS  DERIVATIVES 
(BEOMIDES,     BROMATES,     ETC.) .  — 

Bromine  is  a  dark-reddish-brown,  vola- 
tile fluid,  emitting  pungent  and  acrid 
fumes,  caustic  in  action  and  taste.  It 
is  sparingly  soluble  in  water  (1  to  33), 
very  soluble  in  chloroform,  and  likewise 
in  ether  and  alcohol,  both  of  which, 
however,  it  gradually  decomposes.  It 
combines  freely  with  bases  to  form  salts. 

As  regards  the  bromates,  the  small 
proportion  of  bromine  contained  entitles 
them  to  consideration  only  in  connection 
with  their  respective  bases.  The  list  of 
bromides  is  somewhat  extended,  there 
being  no  less  than  seventeen  salts,  and 
these,  with  half  a  dozen  bromates  and  a 
number  of  other  compounds,  bring  the 
total  of  bromine  derivatives  up  to  thirty- 
one.  Some,  however,  are  to  be  regarded 
as  chemicals  purely,  or  chemical  curiosi- 
ties, rather  than  medicaments,  and  a  few 
are  so  rare  or  expensive  as  to  inhibit  gen- 
eral employment. 

Bromide  of  ammonium  is  a  white, 
granular  salt  that  may,  however,  with 
exposure  to  light  and  air  take  on  a  more 
or  less  yellowish  hue.  Its  action  is  prac- 
tically the  same  as  that  of  the  potassium, 
sodium,  calcium,  lithium,  and  strontium 
salts,  at  least  as  regards  the  nervous  sys- 
tem.   It  also,  in  small  doses,  is,  to  some 


extent,  an  alterative  and  hepatic  stimu- 
lant; but  in  this  particular  is  no  better 
than,  and  perhaps  not  so  active  as,  potas- 
sium bromide.  It  is  the  least  palatable  of 
the  bromine  salts,  has  a  pungent,  saline 
flavor  (bromine  taste),  and  is  odorless. 

Calcium  bromide  is  capable  of  evolv- 
ing 80  per  cent,  of  bromine:  a  propor- 
tion greater  than  obtains  to  any  other 
bromide;  hence  it  has  been  lauded  as  a 
succedaneum  for  all  the  salts  of  alkaline 
base.  It  is  had  as  a  white,  deliquescent 
salt,  possessed  of  the  usual  pungent 
saline  taste. 

Lithium  bromide  presents  much  the 
same  physical  properties  as  the  fore- 
going; is  sharp  and  bitter  to  the  taste, 
white,  granular,  odorless,  and  the  most 
difficult  of  all  the  salts  to  keep,  owing  to 
its  deliquescent  character. 

Potassium  bromide  appears  as  color- 
less, odorless,  cubical,  translucent,  non- 
hygroscopic  crystals  of  bitter,  pungent, 
saline  taste,  and  contains  an  average  of 
67  per  cent,  of  bromine. 

Sodium  bromide  exhibits  a  consider- 
ably larger  percentage  (77.5)  of  bromine 
than  its  potassic  congener,  and,  though 
it  has  characteristic  bromine  taste,  it  is 
most  palatable  of  all  the  salts,  and  the 
best  borne  by  the  stomach,  though  this 
latter  claim  has  been  disputed  in  favor 
of  strontium  bromide.  It  is  a  white, 
odorless  salt,  fairly  permanent  under  all 
ordinary  conditions  of  the  atmosphere, 
and  is  found  in  the  shops  in  two  forms: 
as  a  granular  powder  and  as  small,  mono- 
clinic  crystals. 

Strontium  bromide  is  a  comparatively 
recent  addition  to  the  materia  medica, 
and  occurs  in  colorless,  odorless  crystals, 
only  less  deliquescent  than  lithium  bro- 
mide, and  possessed  of  the  usual  bitter, 
saline  flavor;  it  contains  65  per  cent,  of 
bromine. 

Bromal,    tribromaldehyde,    or    tribro- 


634 


BROMINE.    PREPARATIONS. 


maeetyl-oxide,  is  a  limpid,  colorless,  oily 
liquid  possessed  of  a  peculiar,  sharp  odor 
and  irritating  taste,  obtained  through 
the  decomposition  of  alcohol  by  bro- 
mine; it  is  soluble  in  water,  alcohol, 
and  ether,  but  is  not  employed  medic- 
inally. Its  derivative,  bromalhydrate, 
however,  was  introduced  with  a  view  of 
affording  an  analogue  of,  and  substitute 
for,  chloral-hydrate,  but  has  failed  to 
secure  the  favor  of  medical  men  so  con- 
fidently expected.  It  is  a  crystalline 
solid  with  the  taste  of  bromal. 

Bromalin,  or  bromethylformamide, 
contains  only  about  half  as  much  bro- 
mine as  potassium  bromide, — i.e.,  about 
34  or  35  per  cent., — and  offers  no  ad- 
vantages over  the  common  bromide  salts; 
hence  requires  little  attention.  It  must 
not  be  confounded  with  hromelin:  a 
preparation  representing  the  digestive 
principle  embodied  in  the  pine-apple. 

Bromamide  is  a  synthetic  body  ob- 
tained by  the  union  of  bromine  and 
formamide,  and  occurs  in  colorless,  odor- 
less, needle-shaped  crystals  insoluble  in 
hot,  but  slightly  soluble  in  cold,  water, 
freely  so  in  hot  alcohol,  and  also  in 
ether. 

Bromol,  or  tribromphenol,  like  the 
preceding,  is  a  synthetic  product,  had  by 
the  action  of  bromine  on  an  aqueous 
solution  of  carbolic  (phenic)  acid;  it  is 
precipitated  as  silky  crystals  that  are  in- 
soluble in  water,  but  readily  soluble  in 
alcohol,  chloroform,  ether,  glycerin,  and 
fats. 

The  bromates  can  hardly  properly  be 
considered  in  connection  with  bromine 
and  the  bromides,  since  their  therapeu- 
tic relations  are  markedly  those  that  ob- 
tain to  their  base,  hydrobromic  acid 
excepted.  The  proportions  of  bromine 
are  comparatively  small  as  compared 
with  bromides,  though  it  must  be  ad- 
mitted that  their  action  as  salts  is,  in 


considerable  measure,  different  from 
that  of  their  alkaloidal  derivatives. 

Preparations  and  Doses.  —  Bromine, 
external  use  only. 

Bromide  of  ammonium,  10  to  60 
grains. 

Bromide  of  arsenic  (Clemens's  solu- 
tion), 1  to  5  minims. 

Bromide  of  barium,  ^/k,  to  1  grain. 

Bromide  of  cadmium,  ^/g  to  V4  grain. 

Bromide  of  calcium,  30  to  90  grains. 

Bromide  of  camphor  (monobromated 
camphor;  camphor  monobromide),  3  to 
10  grains.    See  Camphor. 

Bromide  of  ethyl  (inhalation  only). 
See  Bromide  of  Ethyl. 

Bromide  of  gold,  Vs  to  V2  grain.  See 
Gold. 

Bromide  of  iron,  3  to  10  grains.  See 
Iron. 

Bromide  of  lithium,  20  to  150  grains. 

Bromide  of  mercury,  Vj  to  1  grain. 
See  Mercury. 

Bromide  of  nickel,  2  to  10  grains. 
See  Nickel. 

Bromide  of  potassium,  10  to  120 
grains. 

Bromide  of  silver,  V4  to  1  grain.  See 
Silver. 

Bromide  of  sodium,  20  to  150  grains. 

Bromide  of  strontium,  30  to  150 
grains. 

Bromide  of  zinc,  1  to  3  grains.  See 
Zinc. 

Bromal,  1  to  3  grains. 

Bromalhydrate,  ^/j  to  5  grains. 

Bromalin,  10  to  130  grains. 

Bromamide,  10  to  15  grains. 

Bromoform,  anaesthetic  and  antispas- 
modic, 1  to  7  drops  according  to  age. 

Bromol,  ^/jg  to  ^/g  grain. 

Bromohydric  acid,  dilute,  2  to  120 
minims.     See  Hydrobromic  Acid. 

Bromohydrate  of  caffeine,  1  to  6 
grains.    See  Coffee. 


BROMIDES.     UNTOWARD  EFFECTS. 


635 


Bromohydrate  of  conine,  V30  to  Vi„ 
grain.    See  CoNiuii. 

Bromohydrate  of  quinine,  1  to  20 
grains.    See  Quinine. 

Bromohydrate  of  scopolamine,  Vjeo  to 
Vioo  grain.    See  Scopolamine. 

Bromoliydrate  of  strychnine,  ^/^o  to 
V20  grain.    See  Strychnine. 

Untoward  Effects  and  Physiological 
Action. — Bromine,  per  se,  cannot  be  ad- 
ministered internally  because  of  its  poi- 
sonous and  powerfully  corrosive  prop- 
erties. When  brought  in  contact  with 
organic  matters  it  rapidly  oxidizes  and 
destroys  them;  hence  its  chief  use  is  as 
a  disinfectant  (1  to  500);  it  also,  some- 
times, for  like  reason,  finds  employment 
as  a  topical  application  in  hospital 
gangrene,  phagedenic  ulcers,  sloughing 
chancroids,  and  like  morbidities. 

The  common  bromine  salts  are  in  a 
general  way  identical  in  action,  the  chief 
difference  being  intensity  and  palata- 
bility,  which,  of  course,  are  determined 
by  the  amount  of  bromine  each  contains, 
and  the  character  of  its  base.  Potassium 
bromide  is,  perhaps,  the  salt  best  known 
and  most  generally  employed,  and  a 
general  description  of  its  physiological 
properties  may  be  considered  as  typical 
of  the  ammonium,  calcium,  lithium, 
sodium,  and  strontium  salts. 

Originally  potassium  bromide  was  in- 
troduced as  an  alterative  and  resolvent, 
and  substitute  for  the  iodide  salt,  and 
in  small  doses  it  often  answers  these 
purposes.  But  no  sooner  was  its  seda- 
tive action  on  the  nervous  system  made 
apparent  than  its  earlier  uses  were  lost 
sight  of,  and  to  a  degree  that  has  prac- 
tically buried  all  other  properties  in 
oblivion.  It  depresses  the  brain  and 
spinal  cord  in  medium  doses,  rendering 
the  same  markedly  anaemic  if  pushed  or 
exhibited  in  larger  doses.  If  the  doses 
are  still  further  increased  and  continued. 


anaesthesia  of  mucous  membranes  of  eye, 
throat,  and  nose  is  observed,  which, 
doubtless,  extends  to  the  entire  digestive 
and  intestinal  tract,  though  the  evi- 
dences thereof  are  not  markedly  ap- 
parent in  the  rectum.  Bromides  di- 
minish sexual  desire,  and,  when  pushed 
to  the  extreme  of  bromism,  may  destroy 
the  same,  or  at  least  place  in  abeyance 
for  a  considerable  period;  at  the  same 
time  the  contractility  of  muscular  fibre 
is  diminished,  and  capillary  circulation 
retarded.  First  of  all  the  sensory  col- 
umns of  the  spinal  cord  are  depressed 
by  bromides,  next  the  sensory  nerves; 
next  the  brain  and  motor  columns  of  the 
cord;  finally  the  motor  nerves.  While 
small  doses  do  not  seem  to  appreciably 
disturb  the  heart's  action,  larger  ones 
depress,  and,  pushed  to  ultimate  toxicity, 
death  occurs  with  arrest  in  diastole. 

Brominism  is  the  first  definite  meas- 
ure of  toxicity,  and,  unfortunately, 
bromide  of  potassium  and  most  of  its 
congeners  are  eliminated  very  slowly; 
hence  cumulative  action.  The  cerebral 
symptoms  are:  a  sense  of  mental  weak- 
ness, heaviness  of  the  intellect,  and  fail- 
ure of  memory;  partial  aphasia;  great 
somnolence  and  depression  of  spirits  (H. 
C.  Wood).  With  these  there  may  be 
decided  impairment  of  sensibility  of  the 
skin,  to  a  degree  that  considerable  heat 
applied  elicits  no  complaint  (Peeche). 
There  is  usually  violent  frontal  head- 
ache; but  this  often  occurs  ere  the 
stage  of  brominism  is  reached;  and 
bronchial  catarrh  and  cough  sometimes 
supervene.  Where  brominism  assumes 
a  chronic  character,  there  is  a  nauseous, 
foetid  breath,  congestion  and  oedema  of 
uvula  and  fauces,  disturbances  of  sensa- 
tion as  regards  vision  and  audition,  loss 
of  appetite,  and  hallucinations  either 
with  or  without  mania.     Routine  prac- 


626 


BROMIDES.     UNTOWARD  EFFECTS. 


tice  in  prescribing  bromides  may  lead  to 

mania. 

The  pernicious  system  of  prescribing 

bromides    recklessly    for    epilepsy    and 

other   nervons    disorders   may    lead    to 

scTere  mental  diseases. 

On  taking  bromides  a  considerable 
amount  of  bromine  is  retained  in  the 
body,  and  the  output  of  it  only  comes 
to  equal  the  intake  when  the  organism 
has,  as  it  were,  become  saturated  with 
the  element.  If  no  more  bromide  be  then 
taken,  bromine  excretion  goes  on  very 
slowly,  and  its  presence  can  be  recognized 
in  the  urine  for  several  weeks.  Excre- 
tion takes  place  chiefly  through  the  kid- 
neys, but  it  is  also  present  in  all  the 
fluid  secretions.  While  bromides  are  be- 
ing taken,  the  amount  of  chlorides  in 
the  urine  is  greatly  augmented,  and  from 
this  the  conclusion  is  drawn  that  bro- 
mine ousts  chlorine  to  a  certain  extent 
from  its  combinations  in  the  body-  tis- 
sues and  fluids.  During  the  administra- 
tion of  bromides  small  quantities  of 
iodine  are  found  in  the  urine  in  some 
eases,  and  disappear  when  the  bromides 
are  stopped.  The  iodine  seems  to  be  de- 
rived from  that  present  in  the  thyroid 
gland,  but  this  is  not  quite  certain  until 
further  observations  can  be  made.  F. 
Fessel  (Mfinchener  med.  Woch.,  Sept.  26, 
'99). 

A  condition  of  the  brain  may  be  pro- 
duced similar  to  that  occasioned  by  ex- 
cessive haemorrhage;  i.e.,  an  increased 
tendency  to  convulsive  action  (Clark, 
Gowers,  Eosenbach).  The  action  is  not 
only  on  the  cerebral  circulation,  but  also 
in  the  cells  of  the  gray  matter  of  the 
cord. 

Paresis  is  often  induced,  with  in- 
ability to  walk,  sometimes  more  marked 
on  one  side  of  the  body  than  on  the 
other  and  simulating  hemiplegia;  there 
may  be  failure  of  memory,  going  on  to 
partial  paresis,  with  involuntary  move- 
ments of  bowels  and  bladder.  In  a  case 
of  Jacksonian  epilepsy,  in  a  child,  a 
drachm  of  potassium  bromide  was  given 


daily.  The  father,  a  druggist,  reasoned 
that,  if  this  amount  kept  the  disease  in 
check,  2  or  3  drachms  during  the  same 
period  ought  to  work  a  cure.  But  the 
child  speedily  sank  after  the  larger  doses 
were  instilled  and  became  an  imbecile. 
Also  two  children  were  taking  bromide; 
one  lost  all  memory  of  words  and  the 
other  all  idea  of  time. 

Voisin,  Stark,  Kiernan,  Moyer,  Eock- 
well,  Seguin,  Spitzka,  Alexander,  and 
others  have  reported  cases  of  convulsions 
arising  from  traumatic  epilepsy  that, 
under  the  influence  of  bromides,  were 
replaced  by  furor.  Cases  of  grand  mal 
and  petit  mal  have  been  reported  in 
which  their  use  rendered  the  patients 
unmanageable,  violent,  homicidal,  queru- 
lous, irritable,  and  suspicious. 

The  last  author  quoted  cites  several 
more  cases,  eight  in  all.  L.  W.  Baker, 
of  Baldwinsville,  three  more.  Laborde 
also  observed  priapism  and  sexual  ex- 
citement sometimes  amounting  to  saty- 
riasis follow  the  use  of  bromides.  Win- 
ters, of  JSTew  York,  has  recorded  many 
instances  of  visual  hallucinations.  Kier- 
nan, of  Chicago,  and  Numro,  of  Edin- 
burgh, also  observed  marked  aphrodisia. 
"That  these  untoward  effects  closely 
simulate  the  effect  produced  in  epilepsy 
there  can  be  no  doubt,  yet  the  weight 
of  authority,  and  indeed  the  weight  of 
evidence,  is  in  favor  of  the  opinion  that 
these  phenomena  result  most  often  from 
the  suppression  of  epileptic  explosions" 
(Bannister  and  Alexander). 

"To  give  the  bromides  alone  is  to 
postpone  the  explosions  and  generally 
intensify  them.  The  very  fact  that  a 
sudden  suppression  of  bromide  admin- 
istration is  followed  by  a  severe  ex- 
plosion is  clear  evidence  that  the  drug 
acts  rather  like  a  load  keeping  down  a 
safety  valve."  (Spitzka.) 
Not   the   least   unpleasant   sequelae — 


Bromide  of  Potassium  Eruption. 

ATLAS     OE      L'    HOPlTAL     ST.LOUIS, 


BKOMIDES.    UNTOWAKD  EFFECTS. 


627 


both  as  regards  patients  and  medical 
attendants — that  supervene  as  the  result 
of  continuous  bromide  administration, 
even  in  what  are  often  considered  very 
moderate  doses,  are  the  manifestations 
of  brominism  seen  upon  the  skin.  These 
may  range  all  the  way  from  a  simple 
erythema  to  a  rubeoliform  or  scarlatini- 
form  rash,  up  to  acne,  pemphigus,  fu- 
runeular  swellings,  and  most  foul  and 
stubborn  ulcerations  that,  too  often,  per- 
haps, are  deemed  evidences  of  a  syph- 
ilitic diathesis.  These  are,  for  the  most 
part,  distinctly  traceable  to  morbid 
changes  in  the  sebaceous  glands,  in  turn 
induced  by  impeded  capillary  circula- 
tion and  obtunded  nerve-fibrillEe.  Such 
eruptions,  if  not  recognized,  are  very 
annoying  to  treat,  and  are  practically 
impossible  to  relieve  until  the  bromide 
is  suspended  and  in  great  measure  elim- 
inated from  the  system.  It  is  claimed 
that  the  simultaneous  administration  of 
arsenic  tends  to  inhibit  such  sequelae; 
but  this  is  not,  by  any  means,  univer- 
sally true.  The  late  Brown-Sequard  was 
accustomed  to  combine  belladonna  with 
bromides,  which  frequently  proves  a 
most  effective  measure. 

Case  of  a  robust,  well-developed  child, 
3  years  of  age,  suffering  from  an  ulcer 
on  calf  of  leg,  resembang  a  boil,  covered 
at  the  apex  with  raspberry  granulations 
bathed  in  adhesive,  sanious  pus.  In  a 
few  days  the  ulcer  was  surrounded  with 
acne  pustules,  which  coalesced  with  the 
original  lesion  until  the  latter  covered 
a  large  part  of  the  gastrocnemius  mus- 
cle; skin  tawny  or  bronze;  breath 
very  offensive.  The  pustules  were  im- 
mense, and  resembled  varicella  more 
than  acne.  Finally  the  sores  threatened 
the  whole  leg  below  the  knee.  It  was 
found  the  child  occasionally  suffered  at- 
tacks of  vertigo,  for  which  a  neighboring 
physician  with  a  repiitatioi^  for  "curing 
fits"  had  prescribed  large  doses  of  am- 
monium bromide,  under  the  supposition 
that  he  was  treating  a  case  of  epilepsy. 


Fullerton  (Memphis  Med.  Monthly,  Oct., 
'97).     {See  colored  plate.) 

The  evidence  is  overwhelming  that 
the  bromides  are  not  the  harmless  medic- 
aments that  they  are  generally  assumed 
to  be;  also  that  their  present  universal 
and  routine  employment  should  be 
abandoned  for  more  rational  and  physio- 
logical methods  of  procedure.  When  a 
patient  who  has  been  taking  bromides 
for  some  time  complains  of  a  salty  or 
bitter  taste  soon  after  the  drug  has  been 
ingested,  especially  if  there  is  increased 
secretion  of  saliva,  suggestions  of  foetid 
breath,  or  a  burning  sensation  in  the 
mouth,  whether  accompanied  by  nausea 
and  eructations  or  not,  such  should  be 
regarded  as  evidence  of  impending  bro- 
mism,  and  measures  taken  accordingly. 
It  must  be  remembered,  moreover,  that 
these  evidences  may  result  from  the 
administration  of  ordinary  medicinal 
doses — 10  to  20  grains  in  the  adult — ■ 
when  frequently  repeated,  since  the 
emunctories  are  not  able  to  excrete  this 
amount.  Interstitial  nephritis  is  a  com- 
mon sequel  to  brominism. 

Of  all  the  bromine  salts,  that  of  am- 
monium is  the  most  apt  to  induce  tox- 
icity, since  the  effects  upon  the  sensory 
portion  of  the  spinal  cord  are  most 
marked.  Bromides  of  lithium,  potas- 
sium, and  calcium  rank,  respectively, 
second,  third,  and  fourth  as  regards 
poisonous  qualities.  Collapse  under 
either  the  ammonium  or  potassium  salt 
may  arise  either  through  the  base  or  the 
bromine  constituent;  but  the  potassium 
bromide  is  more  apt  to  be  at  fault  in 
this  respect.  It  is  sometimes  a  difficult 
matter  to  determine  where  the  blame 
should  rest;  but  withdrawal  of  the 
potassium  bromide,  substituting  there- 
for another  salt, — that  of  sodium,  for  in- 
stance,— may  lead  to  definite  decision. 
But  the  most  innocuous  (apparently)  of 


638 


BROMIDES.     UNTOWARD  EFFECTS. 


bromine  salts,  when  long-continued  or 
pushed  to  extremes,  are  apt  to  induce 
collapse;  and  fatal  pathological  changes 
in  both  kidney  and  liver  have  been 
ascribed  to  their  use,  with  considerable 
reason  and  probability.  Calcium  bro- 
mide is  claimed  to  be  the  least  depress- 
ing, but  this  is  not  altogether  borne  out 
by  long  experience  in  its  use. 

Case  of  infantj  subject  of  a  bromide 
eruption.   Child  when  brought  for  treat- 
ment was   7  months  old,  irritable,  and 
dentition  was  in  progress.     It  was  very 
feverish    and    would    not    sleep;    stools 
were   offensive.      A   simple   carminative 
mixture  was  given,  2  grains  of  bromide 
of  ammonium  being  added.     Two  days 
after    commencing    this,    the    rash    ap- 
peared,  and   was   well   marked   on   the 
forehead,  and  there  was  an  extension  to 
the  scalp  and  to  some  extent  to  other 
parts  of  the  body.     The  child  had  been 
very  greatly  relieved  by  the  treatment, 
although  the  rash  was  still  well  marked 
on  the  tenth  day  of  treatment.     Seymour 
Taylor  (Brit.  Jour,  of  Derm.,  May,  '98). 
Lithium  bromide  requires  to  be  ad- 
ministered in  larger  doses  than  its  con- 
geners, and  often  proves  the  most  irri- 
tating of  any  to  the  digestive  system. 
The  strontium  salt  is  least  disturbing  to 
the  stomach  when  continuously  admin- 
istered for  considerable  periods,  and  by 
many  held   the  least  likely  to   induce 
bromism;    indeed,  H.  C.  Wood  believes 
it  stimulates  appetite  and  increases  the 
activity  of  the  digestive  organs,  which, 
however    true    of    small    and    medium 
doses,  at  moderate  intervals,  is  not  a  fact 
regarding  medium  doses  with  brief  in- 
tervals long  continued  or  larger  doses. 
The  chief  advantage  of  the  salt  is  that 
its  base  is  practically  non-toxic.    Barium 
bromide  may  be  dismissed  with  the  state- 
ment that  it  offers  no  advantages  over 
the  other  bromide  salts,  and  it  has  the 
marked    disadvantage    of    possessing    a 
very  poisonous  base.     It  is  also  claimed 
for  this  salt  that  it  stimulates  mucous 


membrane,  improves  appetite  and  diges- 
tion, etc.,  and  though  this  is,  in  a  meas- 
ure, true,  such  are  referable  to  the 
metallic  base  rather  than  the  acid  source. 
Sodium  bromide  is  undoubtedly  the 
most  convenient,  and  to  considerable 
degree  the  most  safe  of  the  bromide 
salts.  Suitably  diluted,  it  is  no  more 
disagreeable  to  the  palate  than  the  bulk 
of  mineral  waters,  and  it  is,  moreover, 
when  accompanied  by  abundance  of 
fliiid,  almost  as  readily  eliminated.  It 
must  be  remembered,  in  employing  this 
drug,  that  it  is  not  only  essential,  but 
of  paramount  importance,  that  the 
system  be  continually  saturated,  and 
flushed,  so  to  speak,  with  water  in 
abundance.  Though  some  doubt  its 
efficacy  as  compared  with  the  ammo- 
nium, calcium,  and  potassium  salts,  it 
certainly  is  least  depressing  to  both  cir- 
culation and  nervous  system,  and  less 
irritating  to  the  emunctories.  In  epi- 
lepsy it  is  questionable  if  the  results 
desired  are  not  those  that  accrue  to 
toxicity  rather  than  those  of  purely 
remedial  character,  for  here  free  stimu- 
lation appears  to  inhibit  prevention  of 
paroxysms.  But  as  a  nerve-sedative 
purely,  continued  experience  with  so- 
dium bromide  invariably  leads  to  in- 
creasing favor  on  the  part  of  both  pre- 
scriber  and  patient,  until  the  verdict  ulti- 
mately becomes  overwhelmingly  positive. 
Bromalhydrate  in  large  doses  is  a 
poison  of  great  intensity,  death  rapidly 
resulting  from  paralysis  of  heart  and 
sometimes  of  respiration  also,  preceded 
by  minutely-contracted  pupils,  marked 
dyspnoea,  and  general  convulsions.  It 
lowers  blood-pressure  by  powerfully  de- 
pressing the  circulation  and  vasomotor 
centres;  it  is  equally  depressant  to  the 
cord,  especially  the  motor  columns 
thereof.  When  employed  in  hypnotic 
doses,  sleep  is  induced  by  direct  action 


BROMIDES.     UNTOWARD  EFFECTS. 


629 


on  the  cerebrum,  causing  brain-anemia. 
Larger,  but  non-toxic,  doses  induce 
distinct  lowering  of  body-temperature. 
Like  chloral,  to  which  it  was  expected  it 
would  prove  an  analogue,  it  is  antisep- 
tic; and  it  is  likewise  markedly  and 
painfully  irritant  to  mucous  membranes 
and  raw  surface.  It  is  eliminated  by  the 
kidneys  but  slowly,  and  in  the  form  of 
urobromic  acid. 

Bromalin,  inasmuch  as  it  contains 
only  about  half  as  much  bromine  as 
potassium  bromide,  requires  to  be  given 
in  large  doses,  but  its  effects  are  sup- 
posed to  be  identical  with  the  latter. 
It  is  claimed,  moreover,  that  it  is  less 
prone  to  provoke  unpleasant  sequels; 
but  clinical  experience  is  not  yet  suffi- 
ciently ample  to  permit  of  drawing 
definite  deductions. 

Bromalin  used  in   two   cases   of  well- 
pronounced     bromine     exanthema.       Al- 
though complete  disappearance  of  the  ex- 
anthema was  not  brought  about  by  the 
remedy,  yet  a  favorable  effect  was  exer- 
cised by  the  bromalin,  which  exhibited 
a   more   powerful    sedative    action   than 
the  potassium  bromide  previously  used. 
Bromalin  is  the  only  remedy  that  per- 
fectly replaces  the  bromides   of  the   al- 
kalies and  that   is  almost  entirely  free 
from  the  by-effects  of  the  latter.    Bijhme 
(E.  Merck's  1898  Bericht). 
Bromamide  evinces  its  chief  activity 
upon  the  cerebrum,  which  it  materially 
depresses;    hence  its  reputation  as  an 
hypnotic;    nevertheless,  it  is  inferior  to 
many  other  drugs  in  this  respect.     In 
larger  doses   it  is  more   markedly   de- 
pressant,  exerting  its  action  upon  the 
spinal  cord,  whereby  it  becomes  an  anal- 
gesic.   In  medium  doses  it  stimulates  the 
respiratory    centres;     but    here,    again, 
when  pushed  to  the  verge  of  toxicity, 
an  opposite  result  accrues  that  may  re- 
sult in  total  paralysis.    In  small  doses  it 
influences  the  circulation  but  little;  but 
in   larger   depresses   the   heart,   and,   if 


increased,  the  action  of  the  organ  is 
entirely  suspended.  Thus  it  is  a  remedy 
far  more  powerful  for  evil  than  good, 
and  furthermore  there  is  little  confidence 
to  be  placed  therein,  since,  once  exposed 
to  air  and  light,  chemical  changes  take 
place  whereby  \t  develops  greater  tox- 
icity. A  dose  taken  from  one  container 
to-day  that  appears  harmless,  if  repeated 
a  week  later  may  prove  dangerous.  Until 
more  is  known  of  the  product,  and  until 
its  manufacture  and  preservation  can  be 
encompassed  by  greater  safeguards,  in- 
suring stability  and  uniformity,  the  drug 
is  best  relegated  to  the  list  of  curious 
chemicals. 

Bromoform  is  best  known  for  its  anaes- 
thetic properties,  but  is  sometimes  ap- 
plied to  relieve  the  pain  accruing  to  cer- 
tain morbid  ulcers,  and  here  appears  to 
be  both  an  antiseptic  and  a  local  anjcs- 
thetic.  After  inhalation  it  may  be  de- 
tected in  the  form  of  hydrobromic  acid 
in  the  urine.  It  is  highly  toxic,  more- 
over, and  induces  symptoms  of  collapse, 
accompanied  by  great  weakness,  cya- 
nosis, dilated  and  fixed  pupils,  and  cold- 
ness of  extremities,  but  seems  to  be 
easily  eliminated  from  the  system  under 
the  use  of  stimulants  and  tepid  baths. 

Case  of  a  child,  10  months  old,  that 
took  by  inadvertence  about  a  drachm  of 
bromoform.  In  a  short  time  slight  cya- 
nosis had  developed,  the  pupils  were  pro- 
foundly contracted  and  phenomena  of 
respiratory  and  cardiac  paralysis  had 
made  their  appearance.  The  tongue  pre- 
sented a  brownish  discoloration,  and  the 
breath  the  characteristic  odor.  Artificial 
respiration  was  at  once  instituted,  and 
the  cutaneous  surface  was  stimulated 
through  hot  bathing  and  cold  douches 
to  the  head,  the  tongue  meanwhile  be- 
ing pulled  forward  rhythmically.  These 
measures  were  maintained  for  two  hours, 
when  an  injection  of  ether  was  made. 
This  was  followed  by  trismus  and  spasms 
of  the  extremities.  The  injection  was, 
however,  repeated  twice  at  intervals  of 


630 


BROMIDES.     POISOXING  BY  BROMIDES. 


half  an  hour,  and  gradually  improvement 
began  to  set  in.  Van  Bommell  (Deut. 
med.  Woch.,  No.  3,  '96). 

It  is  probable  that  in  the  system 
bromoform  gives  origin  to  chloroform. 
Rembe   (Der  Kinderarzt,  viii,  49,  '97). 

Bromoform  poisoning  in  a  case  of  per- 
tussis in  an  infant.  The  bromoform  was 
given  in  a  prescription  with  sj'rup  of 
orange-peel,  alcohol,  and  water.  As  the 
specific  gravity  of  bromoform  was  greater 
than  that  of  the  other  ingredients  in  the 
mixture,  it  naturally  sank  to  the  bottom 
of  the  bottle,  and  the  mixture,  in  order 
that  it  be  properly  given,  should  have 
been  thoroughly  shaken  before  adminis- 
tering it.  This  not  having  been  done,  the 
bromoform  precipitated,  and  must  have 
been  given  in  one  dose  in  the  last  tea- 
spoonful  contained  in  the  bottle.  This 
showed  the  importance  of  prescribing 
this  drug  in  its  pure  form,  without  the 
addition  of  any  diluent.  Louis  Fischer 
(Annals  of  Gynec.  and  Fed.,  June,  '97). 

Simple  formula  for  bromoforra-and- 
chloroform   mixture: — 

IJ  Bromoform,  18  grains. 
Chloroform,  8  minims. 
Rum,  4  fluidounces. 

Whereas  alcoholic  solutions  of  bromo- 
form precipitate  in  excess  of  water,  this 
mixture  with  chloroform  does  not  pre- 
cipitate, no  matter  what  are  the  propor- 
tions of  water  present.  Gay  (Jour,  of 
Med.  of  Bordeaux;  La  Sem.  Mi5d.,  No. 
II,  1900). 

Two  cases  of  bromoform  poisoning; 
the  children  found  lying  side  by  side, 
with  breath  smelling  strongly  of  bromo- 
form, with  faces  pale,  eyes  closed,  pupils 
contracted,  and  limbs  flaccid.  Artificial 
respiration,  brandy  and  strychnine  hypo- 
dermically  administered,  and  lavage  with 
hot  water  and  hot  coffee  brought  con- 
sciousness in  about  one  and  one-half 
hours.  Stokes  (Brit.  Med.  Jour.,  May 
26,  1900). 

Case  of  bromoform  poisoning  in  a  girl, 
aged  6  years,  who  took  I  */;  drachms  of 
pure  bromoform.  Patient  became  un- 
conscious. There  was  no  pulse  at  the 
wrist,  the  heart  was  beating  very  irregu- 
larly about  120  per  minute,  the  respira- 
tions  were   verv    shallow    and    about   S 


per  minute,  the  face  and  lips  were  livid, 
and  pupils  were  pin-point  and   did  not 
react    to    light.      Lavage    with    sodium- 
bicarbonate  solution,  then  Condy's  fluid, 
followed  by  strong  eoflfee  and  sal  vola- 
tile both  by  tube  and  per  rectum  were 
efficient  means  of  treatment.     T.  Brown 
Darling  (Brit.  Med.  Jour.,  June  2,  1900). 
Bromol  has  a  peculiarly  disagreeable, 
pungent  odor,  and  a  sweetish,  astringent, 
but  not  unpleasant  taste,  and,  as  may  be 
imagined  from  its  derivation,  is  power- 
fully  antiseptic.     It  is   unfortunate   it 
should  have  secured  a  designation  that 
is  likely  to  cause  it  to  be  confounded 
with  bromal.    It  has  been  employed  both 
externally  and  internally,  but  definite 
data  are  lacking  regarding  physiological 
properties  when  introduced  into  the  liv- 
ing   economy.      Bearing    in    mind    its 
source,    it    should,    for    the    present    at 
least,  be  regarded  as  a  drug  demanding 
great  caution  in  its  employment.     It  is 
said  to  be  excreted  by  tlie  kidneys  as 
tribromphenolsulphuric  acid. 

Poisoning  by  Bromides. — It  has  re- 
peatedly been  denied  that  bromides  per 
se  ever  induce  fatalities,  but  the  evidence 
already  deduced  is  proof  sufficient  of 
their  dangerous  character.  Careful  ex- 
amination of  literature  also  reveals  the 
fact  that  fatalities  are,  by  no  means,  of 
infrequent  occurrence,  and  the  sus- 
picion is  forced  that  many  deaths  that 
should  have  been  ascribed  to  the  toxic 
action  of  bromides  have  been  ignored 
or  mistakenly  ascribed  to  the  malady  for 
which  the  drugs  were  prescribed. 

Hameau  reports  case  of  a  young 
woman  who  took  four  and  one-half 
pounds  of  bromide  during  ten  months, 
and  while  in  a  condition  of  cachexia 
with  yellowish  skin,  copper-colored 
eruption  on  forehead,  colic,  gastralgia, 
etc.,  suddenly  became  greatly  pros- 
trated; had  delirium  with  profuse 
sweats,  followed  by  death  in  four  days. 
H.  C.  Wood  ("Principles  and  Practice 
of  Ther.,"  '94). 


BROMIDES.    POISONING.    TREATMENT.    THERAPEUTICS. 


631 


Case  of  a  woman  who  took  five  pounds 
of  potassium  bromide  in  less  than  a 
year,  and,  while  having  very  pronounced 
sj^mptoms  of  brominism,  was  seized  with 
delirium  and  suffered  from  hallucina- 
tions of  sight  and  hearing;  declared  she 
was  being  poisoned.  Death  followed. 
Eigner  (Wiener  med.  Presse,  Nos.  25-34, 
'96). 

A  number  of  deaths  can  only  be  ex- 
plained by  the  inordinate  use  of  bro- 
mides. The  patients  sink  into  a  condi- 
tion of  apathy  from  which  they  cannot 
be  roused.  Have  seen  three  autopsies 
and  have  knowledge  of  five  more 
wherein  the  excessive  use  of  bromide 
salts  gave  rise  to  fatality.  Janeway 
( Amer.  Medico-Surg.  Bull.,  May  16,  '96) . 

Bromof orm,  owing  to  its  kinship  with, 
chloroform,  is  an  active  toxic  and  its  ad- 
ministration should  be  carefully  watched. 
In     bromoform     poisoning     attention 
must  chiefly  be  given  to  the  heart  and 
lungs.     The  heart  is  stimulated  by  in- 
jections of  ether  and  camphor.     As  re- 
gards the  respiration,  the  head  should 
overhang,  the  mouth  be  kept  open,  the 
tongue  drawn  forward,  and  the  mucus 
cleared   out   of   the    larynx.     Artificial 
respiration     and     faradization     of     the 
phrenic     nerves     should     be     adopted. 
There   is   no   specific   antidote.     Bijrger 
(Munch,  med.  Woch.,  May  19,  '96). 

Case  of  bromoform  poisoning  success- 
fully treated  by  giving  the  child  an 
emetic  and  an  hypodermic  injection  of 
'/i2o  grain  of  strj'china.  The  bromoform 
precipitated  in  the  mixture  and  the 
greater  part  of  it  was  consequently 
given  in  the  last  dose.  W.  E.  Cheyney 
(Archives  of  Pediatrics,  Feb.,  '97). 

Treatment  of  Bromism.  —  This  con- 
sists, first  of  all,  in  suspending  the  drug; 
next  in  promoting  excretion  by  the 
emunctories,  the  kidneys  and  skin  espe- 
cially, coupled,  if  need  be,  with  support- 
ing treatment  to  heart  and  general  cir- 
culation, and  endeavors  to  restore  to 
normal  the  status  of  the  nervous  sys- 
tem. The  mercurial  salts  are  often  of 
marked  value,  especially  the  iodide  as 
found  in   combination  with   arsenic   in 


Donovan's  solution.  Occasional  purges 
by  large  doses  of  calomel  are  also  very 
efEective,  and,  when  given  to  the  amount 
of  30  to  50  grains  at  bed-time,  this  drug 
is  not  only  without  depressing  after- 
effects, but  tends  to  stimulate  the  kid- 
neys and  emunctories  to  renewed  ac- 
tivity. 

Theoretically,  pilocarpine,  or  jabo- 
randi,  would  be  considered  of  use;  but 
to  an  economy  already  generally  de- 
pressed, with  circulation  and  nervous 
system  suffering  from  the  poison,  these 
might  prove  boomerangs;  atropine  and 
belladonna  are  much  more  preferable 
and  reliable. 

Therapeutics. — The  chief  use  to  which 
the  bromides,  especially  bromide  of  po- 
tassium, have  been  devoted  is  the  treat- 
ment of  epilepsj^  but  the  weight  of  evi- 
dence tends  to  show  that  while  they  may 
decrease  the  number  of  paroxysms,  they 
positively  never  afford  other  relief,  and 
many  times  the  condition  resultant  upon 
their  use  is  worse  than  before  treatment 
began.  Again,  at  least  5  per  cent,  of  epi-  ■ 
leptics  cannot  bear  any  bromide,  even  in 
small  doses. 

Use  the  three  salts  in  epilepsy — am- 
monium, potassium,  and  sodium  — in 
combination  in  doses  of  from  40  to  80 
grains  morning  and  evening.  In  strictly 
nocturnal  seizures  one  dose  at  night 
only.  Treatment  should  be  persisted  in 
for  at  least  three  years.  Arsenic  is 
a  valuable  adjunct  to  the  bromides. 
Eulenberg  (Ther.  Monats.,  Nov.,  Dec, 
'92). 

When  a  bromide  is  given  in  conjunc- 
tion with  borax  the  action  is  better 
than  with  either  salt  alone.  Alexander 
(Liverpool  Medico-Chir.  Jour.,  July,  '93) . 
Twelve  eases  of  epilepsy:  8  male  and 
4  females,  of  ages  ranging  from  10  to 
50  years;  no  predisposition,  no  syphilis. 
In  4  the  fits  occurred  at  least  once  a 
week,  in  the  other  8  at  intervals  varying 
from  1  to  8  weeks.  Bromide  of  stron- 
tium, 20  grains,  with  5  to  10  grains  of 
bromide  of  ammonium  or  sodium,  were 


633 


BROMIDES.    THERAPEUTICS. 


given  night  and  morning,  largely  diluted 
with  water.     Strontium  increased  rap- 
idly to  60  grains  twice  daily  when  the 
smaller  doses  failed  to  control  the  at- 
tacks.    The   majority    took   the   latter 
drug  without  any  depression,  but  gen- 
erally   -with    the    production    of    acneic 
rash  on  face.      Fowler's  solution  of  ar- 
senic  added  to   the  mixture   controlled 
the  rash  and  increased  appetite.      The 
number    of    attacks    in    all    cases    was 
materially  decreased,  and  in  8  there  was 
no  return  after  intervals  of  from  4  to 
16    months.      Roche     (Med.    Press    i.nd 
Circ,  Aug.  12,  '92). 
It  has  been  recommended  to  combine 
adonis  vernalis  and  codeine  with  bro- 
mides in  the  treatment  of  epilepsy,  but 
careful   investigations   on   the   part    of 
many  observers  are  not  at  all  assuring  in 
this  direction. 

The  cures  do  not  appear  to  be  in  any 
way  effected  save  by  the  bromides  alone, 
and  the  combination  does  not,  in  any 
way,  prevent  the  complications  and  dis- 
agreeable symptoms  which  arise  from  the 
use  of  bromide  salts.  Taty  (Lyon  MSd., 
Dec.  29,  '95;    ibid.,  Jan.  5,  12,  '96). 

Chorea.  Convulsive  and  Paroxys- 
mal Maladies.  —  The  bromides  have 
also  been  extensively  employed  in 
chorea,  but  without  any  great  measure 
of  success.  They  are,  however,  often 
most  effective  in  hysterical  seizures, 
asthma,  the  milder  forms  of  whooping- 
cough  and  puerperal  eclampsia  and  in- 
fantile convulsions;  also  have  been 
lauded  in  tetanus,  laryngismus  stridu- 
lus, and  seizure  that  sometimes  follow 
thyroidectomy. 

Stridulous  laryngitis  in  children  is, 
doubtless,  due  to  inflammation  of  the 
larynx,  the  spasms  being  the  sole  danger. 
Here  60  to  70  grains  of  bromide  of  potas- 
sium should  be  administsred  daily,  even 
to  a  child  so  young  as  four  and  one-half 
years;  intubation  or  tracheotomy  may 
be  added  in  menacing  cases.  Huchard 
(Revue  G6n.  de  Clin,  et  de  Ther.,  No. 
38,  '94). 

The  excitability  of  the  nervous  sys- 
tem and  convulsive  symptoms  that  fol- 


low thyroidotomy  may  be  diminished 
and  suppressed  by  the  use  of  potassium 
bromide.  Gley  (La  Sem.  MSd.,  Apr.  13, 
'92). 

The  symptoms  of  tetanus  in  dogs 
caused  by  total  thyroidectomy  can  be 
overcome  by  large  doses  of  potassium 
bromide;  fifty  animals  operated  upon 
were  thus  kept  for  two  years,  and  two 
more  for  six  years.  Canizzaro  (Deut. 
med.  Woch.,  No.  184,  May    '92). 

Bromoform  has  steadily  been  gaining 
favor  as  a  remedy  for  pertussis. 

Bromoform  employed  in  40  cases  of 
pertussis  with  good  results.  For  chil- 
dren, under  6  months,  the  daily  dose  is 
from  2  to  3  drops,  for  children  of  from 
6  months  to  a  year,  from  3  to  4  drops. 
The  daily  dose  should  be  administered  in 
three  portions.  It  is  prescribed  in  an 
emulsion  made  of  almond-oil,  gum  arabic, 
gum  tragacanth,  cherry-laurel  water,  and 
water.  For  the  first  two  or  three  days 
the  paroxysms  of  coughing  may  appear 
to  be  aggravated,  but  after  the  third  or 
fourth  a  marked  improvement  is  noticed. 
The  remedy,  however,  is  not  uniformly 
successful.  Marfan  (Revue  Internat.  de 
Med.  et  de  Chir.,  Apr.  25,  '96) . 

Results  of  treatment  in  874  cases  of 
whooping-cough,  832  cases  being  out-door 
patients,    the    remainder    being    seen    in 
private  practice.     The  drugs  used  inter- 
nally were  potassium  bromide,  tincture 
of    belladonna,    codeine,    quinine,    anti- 
pyrine,  phenacetin,  antifebrin,  and  bro- 
moform.    Bromoform  acted  better  than 
any  of  the  drugs,  vomiting  and  other  com- 
plications being  almost  unknown  and  the 
beneficial  results  being  observed  in  from 
forty-eight  to  seventy-two  hours.     Eross 
(Jahrb.  f.  Kinderh.,  B.  42,  H.  3  and  4). 
About  a  thousand  cases  of  convulsive 
cough  at  the  polyclinic  of  Monaco  treated 
with  bromoform,  all  with  most  favorable 
results.     In  order  to  avoid  all  danger  of 
poisoning,  the  adoption  of  a  mixture  with 
alcohol    and    glycerin    is    recommended. 
Mueller    (Miinch.   med.   Woch.,   No.    38, 
'98). 
Heart  Disorders. — In  cardiac  neu- 
ritis and  in  angina  pectoris  the  bromides 
have  been  recommended,  though  it  is 
admitted,  as  regards  the  latter  malady, 


BROI\nDES. 


BRONCHIECTASIS. 


633 


that  only  excessive  closes  can  be  of  bene- 
fit; in  the  former  the  most  that  can  be 
expected  is  to  obtund  the  reflexes,  and 
this  is  equally  true  of  their  use  in 
Meniere's  disease  and  attacks  of  nervous 
vomiting. 

In  acute  attack  of  M6ni6re's  disease 
efforts   should   be   made   to   subdue   the 
excitability   of  the   nerve-centres.     Bro- 
mide of  potassium,  10  to  20  grains  three 
times  daily,  and  rest  in  the  recumbent 
position  usually  suffice  to  relieve.    Mae- 
Kenzie   (Brit.  Med.  Jour.,  May   5,  '94). 
A  girl,   8   years   of   age,   of   neurotic 
parentage,  had  curious  attack  of  vomit- 
ing at  intervals  of  about  six  weeks  each; 
the  vomited  matter  was  highly  acid,  and 
there   was   a  burning   sensation   in   the 
stomach.     Potassium  bromide,  and  also 
chloral,  per  rectum,  proved  useful.    Snow 
(N.  Y.  Med.  Jour.,  July  1,  '93). 
Dtsmenoeehcea.  —  Sir    James    Y. 
Simpson  was  wont  to  rely  upon  potas- 
sium bromide  in  connection  with  guaiac 
and  magnesia  for  the  treatment  of  func- 
tional dysmenorrhoea,  and  the  sodium 
salt  in  conjunction  with  gelsemium  has 
proved  most  beneficial  in  the  hands  of 
many.    Bromides,  too,  are  often  of  value 
in  the  casual  forms  of  mental  alienation 
that  appear  in  very  nervous  females  and 
are  ascribed  to  the  menstrual  function. 
There  is  an  intimate  relation  between 
menstruation  and   insanity.     The   prog- 
nosis in  menstrual  insanity  is  favorable, 
and   the   treatment   resolves   itself   into 
the  use  of  general  and  ovarian  sedatives, 
specially  the  bromides.    Ball  (Journal  de 
Med.,  Mar.  20,  '92;    Annales  d'Hypnol. 
et  de  Psych.,  Feb.,  '92). 

In    four    cases   the   administration    of 
bromide  of  sodium  induced  erection  and 
seminal  emissions.     The  same  drug  pro- 
duced orgasm  in  a  girl;    and  in  a  boy 
suffering  from  seminal  emissions  as  the 
result  of  masturbation  the  trouble  was 
increased.     Monroe    (Med.  Stand.,  May, 
'91). 
Infectious  Diseases. — Especially  in 
the  exanthemata  and  infectious  diseases 
the  bromides  often  prove  of  the  utmost 


value  if  given  in  small  and  often-re- 
peated doses,  in  allaying  nervous  excite- 
ment and  combating  insomnia. 

Bromal  has  given  good  results  in  diph- 
theria when  dissolved  in  glycerin  (1  to 
25)  and  applied  topically  to  throat.  Also 
internally  in  cholera  infantum,  in  doses 
of  from  Vu  to  V»  grain.  Rademaker 
(Lancet,  London,  Oct.   10,  '91). 

Reflex  hemicrania  from  carious  tooth 

relieved  in  three  hours  by  a  15-grain  dose 

of   bromamide;     premenstrual    headache 

in   like  manner  relieved   in   two  hours. 

Relieves  rheumatic  pains.    Best  given  in 

capsules,  suspended  in  fluid,  or  dry  on 

the  tongue.     Caill6    (N.   Y.  Med.  Jour., 

Feb.  20,  '92). 

Gout. — In  some  gouty  people  Brun- 

ton  has  found  20  grains  of  potassium 

bicarbonate   with    10    to   20   grains   of 

potassium  bromide  useful,  taken  when 

the  feeling  of  irritability  comes  on.     It 

frequently    soothes,    and,    furthermore, 

has  the  effect  of  lessening  worry  even 

in  those  who  are  not  irritable. 

Brunton  also  finds  potassium  or  so- 
dium bromide  and  sodium  salicylate  of 
value  in  the  irritability  of  temper  that 
is  sometimes  a  precursor  of  headache, 
and  likewise  in  heart  disease.  But  bro- 
mides are  contra-indicated  in  the  car- 
diac depression  that  accrues  to  an  alco- 
holic or  opium  debauch,  and  moreover 
are  most  dangerous.  Such  are  cases  re- 
quiring bread  and  are  offered  stone;  the 
already-depressed  heart  and  nervous  sys- 
tem demand  toning  up  and  stimulation, 
whereas  the  bromine  preparations  make 
the  patient  worse. 

G.  Archie  Stockwell, 

New  York. 

BRONCHIAI  TUBES,  FOREIGN 
BODIES  IN.  See  Eespibatort  Pas- 
sages, Foreign  Bodies  in. 

BRONCHIECTASIS. 

Definition. — A  more  or  less  uniform 
dilatation  of  the  bronchial  tubes,  of  one 


634 


BRONCHIECTASIS.    VARIETIES.    SYJtPTOMS. 


or  both  lungs,  which  may  be  localized  or 
extend  to  the  finer  ramifications. 

Varieties.  —  The  dilatation  may  be 
cylindrical,  involving  the  medium-sized 
tubes  and,  less  frequently,  the  smaller 
bronchi  and  bronchioles,  or  saccular,  the 
caliber  of  limited  portions  of  the  bronchi 
being  enlarged,  and  forming  bag-like 
cavities  of  various  dimensions.  "Bron- 
chiolectasis"  is  a  term  proposed  by  Kan- 
thack  for  those  cases  in  which  only  the 
bronchioles  are  involved. 

Symptoms.  - —  In  practically  all  the 
eases  of  bronchiectasis  there  is  a  his- 
tory of  prolonged  bronchitis,  of  pleu- 
risy, catarrhal  pneumonia,  broncho- 
pneumonia, or  some  other  acute  pulmo- 
nary disorder.  A  few  follow  the  inhala- 
tion of  some  foreign  body  of  sufficient 
size  to  occlude  a  bronchus.  When  bron- 
chiectasis follows  bronchitis,  the  symp- 
toms of  this  disease  assume  a  modified 
character:  the  cough  becomes  more 
severe  and  paroxysmal  and  the  amount 
of  expectorated  material  is  greatly  in- 
creased. This  copious  expectoration — 
which  may  reach  over  a  pint  a  day 
• — especially  occurs  early  in  the  morn- 
ing or  after  a  sudden  change  of  post- 
ure, even  when  the  patient  is  in  bed. 
At  first  giving  off  a  sour  odor,  it  gradu- 
ally becomes  foetid,  and  this  foetor  be- 
comes so  marked  that  the  atmosphere 
around  the  patient  is  almost  unbearable. 
In  cases  of  long  duration  the  expectora- 
tion is  brownish  and,  when  examined 
microscopically,  is  found  to  contain 
Charcot-Leyden  crystals  and  masses  or 
bundles  of  fatty-acid  crystals.  Various 
kinds  of  bacteria,  leptothrices,  etc.,  are 
also  found,  some  of  which  are  of  external 
origin.  The  tubercle  bacillus  is  seldom 
detected  unless  the  patient  be  concomi- 
tantly suffering  from  tuberculosis  of  the 
lungs. 

The   temperature,   which   during   the 


presence  of  bronchitis  alone  may  have 
been  normal  or  slightly  above  the  normal 
level,  now  shows  a  tendency  to  rise  near 
evening.  The  curve  is  irregular  and 
may  reach  105°.  When  the  disease  fol- 
lows pulmonary  disorders,  attended  with 
pyrexia,  this  is  increased  with  the  ac- 
cession of  fcetor.  As  a  result  of  septic 
absorption,  manifestations  simulating 
those  of  hectic,  as  observed  in  consump- 
tion, usually  occur,  and  the  patient  may 
succumb.  Pulmonary  gangrene  is  not  an 
infrequent  complication  and  promptly 
leads  to  a  fatal  ending  in  the  vast  ma- 
jority of  cases.  Intense  pain  in  the  head 
in  these  cases  indicates  involvement  of 
the  meninges,  while  the  cerebral  press- 
ure induced  may  give  rise  to  hemiplegia, 
athetoid  movements,  and  finally  stupor. 
This  complication  occurs  in  about  one- 
half  of  the  cases. 

In  children  the  disease  is  frequently 
the  result  of  whooping-cough  or  of  bron- 
cho-pneumonia, the  mechanical  origin 
of  the  dilatation  of  the  bronchi  being 
mainly  due  to  repeated  and  forcible 
coughing,  the  weakened  resistance  of  the 
bronchi  through  infiammatory  softening 
causing  them  to  yield  to  the  undue  air- 
pressure.  This  is  especially  the  case 
when  inflammatory  disorders  involving 
the  bronchi  have  repeatedly  occurred  in 
the  patient.  Cases  of  broncho-pneu- 
monia or  chronic  bronchitis  in  which 
recurrences  have  repeatedly  shown  them- 
selves are  therefore  the  most  prone  to 
bronchiectasis. 

When  the  cylindrical  dilatation  is  not 
great,  the  physical  signs  do  not  differ 
markedly  from  those  observed  in  the 
causative  disorder.  But  a  comparative 
point  of  value  is  that  furnished  by  ex- 
amination during  a  fit  of  coughing,  when 
marked  gurgling  may  usually  be  noticed, 
which  gurgling  varies  according  to  the 
amount  of  accumulated  secretion.    Dur- 


BRONCHIECTASIS.     DIAGNOSIS.      ETIOLOGY. 


635 


ing  normal  and  even  deep  respiration 
increased  roughness  as  compared  to  the 
ordinary  signs  of  the  primary  disorder 
may  be  present;  but  the  information 
thus  obtained  is  not  sufficiently  dis- 
tinctive to  warrant  for  this  symptom 
more  than  a  confirmatory  position  among 
the  signs  present.  Loud  gurgling  dur- 
ing coughing  and  foetor  of  the  sputum 
are  conjointly,  however,  strong  evidences 
that  bronchiectasis  is  present. 

When  distinct  saccular  bronchiectasis 
is  present,  the  characteristic  signs  of  pul- 
monary cavities  are  pre-eminent,  but 
most  marked  in  the  majority  of  cases  at 
the  base  instead  of  the  apex  of  the  lung 
involved.  Cavernous  and  amphoric  signs 
are  usually  marked.  The  disease  being 
unilateral  in  a  larger  proportion  of  the 
cases,  confusion  with  tuberculosis  is  pos- 
sible when  the  left  side  is  involved,  and 
when  the  bronchial  dilatation  is  not  con- 
fined to  the  base. 

In  many  cases  in  whicli  the  diagnosis 
is  doubtful,  or  the  auscultatory  signs  do 
not  give  reliable  results  and  fail  to  lo- 
calize with  precision  the  bronchieetasie 
cavities,  the  Roentgen  rays  will  reveal 
them    on    the    fluorescent    screen.      A 
radiographic  examination  will,  in  most 
instances  of  multiple  cavities,  reveal  the 
presence   of   all.     Radioscopy,   however, 
is  not  an  absolutely  infallible  means  of 
diagnosis.     Tuffier   (Bull,  et  Mem.  de  la 
Soc.  de  Chir.,  Mar.  6,  1900). 
When   bronchiectasis    is    due    to    the 
presence  of  a  foreign  body,  it  is  caused 
by   the   violent    cough   induced,    which 
gives  rise  to  undue  pressure  within  the 
tubes.    The  excessive  coughing  may  also 
cause  free  portions  of  the  lung  to  be- 
come dilated.    The  same  condition  may 
be  brought  about  by  stricture  or  com- 
pression occurring  in  the  course  of  mor- 
bid processes  which  mechanically  inter- 
fere with  the  free  passage  of  air  through 
the  tubes.    It  may,  in  this  manner,  com- 
plicate phthisis  and  aneurism. 


Diagnosis.- — The  conditions  for  which 
bronchiectasis  is  apt  to  be  taken  are  pul- 
monary tuberculosis  and  circumscribed 
empyema. 

PULMONAET   TUBEECULOSIS. In   this 

disease  tubercle  bacilli  are  usually  found 
in  the  sputum.  The  lesions  are  located 
at  the  apex  of  either  lung,  generally  the 
left;  while  in  bronchiectasis  they  are 
more  disseminated  and  involve  the  base. 
In  tuberculosis  there  is  a  history  of 
hasmoptysis,  gradual  loss  of  flesh  and 
strength,  and  the  cough  is  not  inclined 
tc  be  paroxysmal.  This  disease  occasion- 
ally acts  as  the  exciting  cause  of  bron- 
chiectasis, however,  and  the  apex  may  be 
the  seat  of  bronchial  dilatation. 

ClECUMSCEIBED     EMPYEMA. In     this 

disease  there  is  a  clear  history  of  acute 
onset,  with  pleuritic  symptoms,  and  a 
sudden  evacuation  of  large  quantities  of 
pus.  The  dyspnoea  is  not  usually  of  long 
standing  and  generally  comes  on  with 
comparative  suddenness.  Distinct  dull- 
ness over  the  purulent  area  serves  to  in- 
dicate the  true  condition  present. 

The  data  for  forming  a  correct  diag- 
nosis are:  The  sputum,  especially  as  re- 
gards (a)  foetor,  (1))  daily  amount,  (c) 
physical  characters,  and  (d)  method  of 
expectoration.  Fcetor  of  breath  on 
coughing.  Physical  signs  of  chest,  in- 
cluding the  signs  of  cavities,  especially 
in  relation  to  (a)  their  size,  distribu- 
tion, occurrence,  and  symmetry;  (b) 
their  generally  non-progressive  char- 
acter and  daily  variations.  The  tem- 
perature-range in  bronchiectasis  varies 
within  very  wide  limits.  It  may  remain 
normal  for  many  weeks  at  a  time,  even 
when  the  sputum  is  offensive.  On  the 
other  hand,  it  may  conform  to  one  of 
the  remittent  or  intermittent  types, 
with  a  range  of  as  much  as  four  or 
five  degrees.  T.  D.  Acland  (Practitioner, 
April,  1902). 
Etiology. — When  chronic  bronchitis 
is  the  primary  cause  of  bronchiectasis 
the  patients  are  usually  past  middle  life. 


036 


BEONCHIECTASIS.     PROGNOSIS.      PATH0L0C4Y. 


with  the  exception  of  the  form  due  to 
foreign  bodies,  wlrich  may  invade  the 
respiratory  tract  at  any  age.  Dilatation 
of  tire  bronchi  is  more  liliely  to  present 
itself  during  early  middle  life.  As 
stated,  it  usually  follows  primary  disor- 
ders of  the  lung,  but  it  is  most  prone  to 
do  so  in  persons  weakened  by  diathetic 
conditions  or  untoward  habits.  Under 
the  former  may  be  classed  alcoholism, 
syphilis,  gout,  and  rheumatism.  Under- 
the  latter  alcoholic  conditions  tending 
to  mechanically  induce  an  increase  of 
the  bronchial  air-pressure  by  interfering 
with  the  free  egress  of  the  atmospheric 
current;  laryngeal  paralyses;  laryngeal, 
infralaryngeal,  and  tracheal  hypertro- 
phic processes;  neoplasms  or  aneurisms 
compressing  the  trachea  or  the  larger 
bronchi;  foreign  bodies  in  any  part  of 
the  inferior  respiratory  tract,  etc.,  are 
as  many  possible  causative  factors.  Ex- 
posure to  cold  and  wet,  dust,  irritating 
gases,  etc.,  tend  to  increase  the  local  dis- 
order by  promoting  the  tendency  to 
local  congestion.  Adenoid  vegetations 
tend  to  predispose  a  child  to  the  affec- 
tion. 

Prog^nosis. — Bronchiectasis  being,  as 
a  rule,  a  secondary  disorder,  its  prog- 
nosis depends,  to  a  great  measure,  upon 
that  of  the  disease  acting  as  cause. 
Again,  the  degree  of  dilatation  induced 
— whether  it  be  cylindrical,  circum- 
scribed, localized,  or  diffused — bears  an 
important  influence  upon  the  course  of 
the  disease.  A  slight  modification  of 
the  bronchial  lumen  does  not  necessarily 
preclude  the  enjoyment  of  practically 
good  health;  when,  however,  the  lumen 
of  the  tubes  is  markedly  increased  or 
studded  with  saccular  dilatations,  the 
infectious  processes  already  described  are 
apt  to  present  themselves  at  any  time 
and  greatly  aggravate  the  danger.  Pro- 
gressive emphysema  and   gangrene  are 


among  the  complications  to  be  expected. 
Dilatation  and  hypertrophy  of  the  right 
ventricle  is  frequently  observed  in  cases 
showing  a  history  of  pertussis.  On  the 
whole,  well-marked  bronchiectasis  does 
not  tend  toward  recovery. 

A  successful  result  is  to  be  hoped  for 
when  appropriate  measures  are  instituted 
at  an  early  date — measures  calculated  to 
aid  Nature's  curative  processes.  This, 
of  course,  emphasizes  the  need  of  an 
early  diagnosis,  for,  when  fibrous  replace- 
ment of  the  pulmonary  parenchyma  has 
occurred  to  any  marked  extent,  a  cure  is 
seldom  obtained.  The  expectoration 
then  persists  and  foetor  recurs. 

Pathology.  —  The  bronchial  tube  in 
some  cases  is  only  temporarily  dilated; 
this  occurs  in  children  after  whooping- 
cough  or  acute  pneumonic  disease.  It  is 
far  more  common,  however,  when  there 
has  once  been  dilatation,  to  have  re- 
peated attacks  of  inflammatory  trouble, 
and  the  dilatation  continually  increasing 
year  by  year.  The  effect  on  the  bron- 
chial tubes  themselves  is  probably  first 
of  all  swelling,  sometimes  observed  in 
the  mucous  membrane,  which  becomes 
velvety  in  appearance;  the  muscular 
coat  of  the  smaller  bronchi  then  becomes 
tumefied  and  its  resistance  is  weakened. 
Owing  to  the  frequent  attacks  there  is 
a  considerable  fibrosis  or  peribronchial 
thickening  around  these  dilated  bronchi. 
In  some  cases,  however,  instead  of  hyper- 
trophy of  the  small  tubes  there  is  thin- 
ning and  dilatation.  When  the  bronchi 
are  large  this  dilatation  is  very  striking. 
On  post-mortem  are  found  large  cavities 
with  many  valvular  reflections  of  the 
mucous  membrane, — an  exaggeration  of 
the  normal  condition  of  the  bronchial 
tube;  so  that  a  large  cavity  seems  to  be 
partitioned  off  by  these  valvular  septa, 
especially  in  the  sacculated  form  of  bron- 
chiectasis;    there    is    a    small    opening. 


BRONCHIECTASIS.    TREATMENT. 


637 


which  is  the  bronchial  tube  leading  to 
it.  Not  only  are  the  bronchial  tubes 
afEected,  but  the  surrounding  area  of 
lung  is  also  involved.  It  is  afEected  iu 
two  ways:  First  an  extensive  inflamma- 
tion spreads  from  the  peribronchial  con- 
nective tissue,  which  is  continuous  with 
the  whole  frame-work  of  the  lung.  This 
tissue  sends  out  delicate  filaments  be- 
tween th€  alveoli  of  the  lung,  and  this 
net-work  is  again  continuous  with  the 
pleura  and  with  the  septa  passing  in 
from  the  pulmonary  pleura.  This  frame- 
work becomes  indurated,  the  chronic  in- 
fliammation  round  the  tubes  continues 
until  there  is  an  interstitial  fibrosis, — 
an  interstitial  thickening  of  the  pulmo- 
nary substance  round  the  dilated  bron- 
chial tubes.  But  such  a  lung  with 
dilated  tubes  is  especially  liable  to  re- 
peated attacks  of  catarrh  or  catarrhal 
pneumonia;  therefore  specimens  some- 
times show  evidences  of  acute  catarrhal 
pneumonia,  but  more  often  those  of  a 
chronic  indurative  pneumonia.  The 
consolidation  due  to  chronic  pneumonia 
is  distinct  from  the  first,  and  is  char- 
act-erized  by  a  reticular  thickening,  or 
fibrosis,  of  the  connective-tissue  elements 
forming  the  frame-work  of  the  lung. 
The  contents  of  the  alveoli  are  in  many 
cases  consolidated,  and  the  appearance 
is  not  of  recent,  but  of  organized,  ex- 
udation. When  stained  with  eosin  and 
hfematoxylin,  the  eosin  picks  out  the 
blood-vessels.  The  centre  of  the  alveoli 
may  thus  be  shown  to  be  filled  with 
small  cellular  elements  and  small  blood- 
vessels, indicating  that  it  is  becoming 
fibroid  and  organized. 

As  the  disease  proceeds  there  occur 
further  complications,  which  end  some- 
times in  death.  In  many  eases  ulcera- 
tion of  the  bronchial  tubes  supervenes. 
In  the  bronchial  tubes  the  retained 
secretions  become  putrid,  full  of  micro- 


organisms, forming  the  foul  sputum 
characteristic  of  such  cases.  Very  often 
this  goes  on  till  ulceration  takes  place, 
and  when  once  ulceration  occurs  any 
form  of  septic  disease  as  a  final  cause  of 
death  may  appear.  Very  common  causes 
are  found  to  be  septic  pneumonia  and 
septic  abscess  in  other  parts  of  the  body. 
Above  all,  abscess  in  the  brain  seems  to 
be  one  of  the  commonest  causes  of  death 
occurring  in  such  cases.  Besides  septic 
pneumonia,  death  may  take  place  from 
acute  catarrhal  pneumonia,  especially 
where  the  patient  has  been  subject  to 
chronic  bronchitis  associated  with  rather 
frequent  attacks  of  acute  broncho-pneu- 
monia.   (Habershon.) 

Autopsy  in  a  case  of  fibroid-lung 
bronchiectasis. 

Lung:  Showing  fibriod  induration. 
The  upper  lobe  is  uniformly  solid,  gray, 
and  very  firm.  The  middle  lobe  is  not 
so  firm.  The  lower  lobe  is  congested 
and  shows  an  area  of  fibrous  induration 
in  the  lower  part.  Extending  through 
these  solidified  portions  are  tubular 
bronchiectasio  cavities  with  blood- 
stained walls. 

Brain:  Section  through  the  right  hem- 
isphere of  the  brain  about  the  paracen- 
tral convolution,  in  the  upper  part  of 
which  is  an  abscess-cavity  the  walls  of 
which  are  Irregular. 

The  association  of  brain-abscess  with 
bronchiectasie    cavities    has    frequently 
been    noted.      Williamson    has    recently 
reported  that  out  of  39  cases  of  brain- 
abscess,  17  were  associated  with  putrid 
bronchiectasis.     Livingood   (Johns  Hop- 
kins Hosp.  Bull.,  Dec,  '97). 
Treatment.  —  A  very  important  point 
in  the  treatment  of  bronchiectasis  is  to 
see  that  the  cavity  or  cavities  are  fre- 
quently emptied.    This  can  generally  be 
effectively   done   by   partially   inverting 
the  patient,  at  first  two  or  three  times  a 
day,  and  later  once  a  day.    The  simplest 
plan  to  adopt  is  for  the  patient  to  hang 
himself  over  the   edge  of  the  bed   or 
couch  so  that  his  legs  rest  on  it  and  his 


638 


BRONCHIECTASIS.     TREATiSIENT. 


body  is  supported  by  his  hands  on  the 
floor.  This  partial  inversion  is  followed 
by  cough  and  the  evacuation  of  a  consid- 
erable amount  of  offensive  sputum. 
(Hector  Mackenzie.) 

Quincke's  suggestion  of  treating  bron- 
chitis   and    bronchiectatie    processes    by 
posture  favored.     In  acute  processes  the 
measure   is   useless.     In   cases   of   foetid 
bronchitis  the  relief  obtained  is  marked. 
The  posture  is  the  dorsal  one  with  the 
foot    of    the    bed    gradually    raised    by 
means  of  bricks.    It  is  practiced  morning 
and  evening  for  an  hour  each.    In  fifteen 
minutes  some  result  should  be  achieved; 
if  no  sputum  is  obtained  by  this  time, 
the    procedure    is    usually    useless.      In 
ordinary  cases  the  entire  day's  secretion 
may  thus  be  evacuated.     O.  Jacobsohn 
(Berliner  klin.  Woch.,  Oct.  8,  1900). 
The  above  suiBciently  illustrates  the 
inadvisability  of  giving  remedies  such  as 
narcotics  to  arrest  the  spasmodic  cough- 
ing:   a  mechanical  device  employed  by 
nature  to  rid  the  dilated  areas  of  ac- 
cumulated  purulent   liquids.     The   so- 
called  ezpectorants  are  useless,  and  the 
disinfectant  aromatics  but  serve  to  mo- 
mentarily check  the  foetor  of  the  breath, 
whether  applied  by  means  of  respirators 
or  atomizers.     The  vapor  or  spray  so 
produced  hardly  penetrates  beyond  the 
trachea.      The    medicaments    employed 
must   reach    the    diseased    areas   either 
directly  or  through  the  blood-current. 
The  intralaryngeal  injection  of  anti- 
septic liquids  recommended  by  Grainger 
Stewart  accomplishes  to  a  degree  the  de- 
sired result  in  the  small  proportion  of 
cases  in  which  the  dilatation  only  in- 
volves the  larger  bronchi. 

A  drawback  connected  with  methods 
in  which  professional  dexterity  has  to 
play  a  role  is  that  the  patient  does  not 
always  receive  as  many  applications  as 
his  condition  would  require  in  order  to 
obtain  the  best  results.  Measures  which 
the  patient  can  carry  out  himself  are 
therefore  always  to  be  preferred. 


A  method  at  once  beneficial  and  easily 
carried  out  is  to  resort  to  the  prone  posi- 
tion, as  described  above,  and  to  admin- 
ister drugs  which  are  eliminated  by  the 
lungs. 

The  allyl  compounds  are  very  effect- 
ive, and  Vivian  Poore  has  recommended 
garlic  as  especially  valuable.  A  "clove" 
of  garlic  is  to  be  chopped  up  and  boiled 
in  beef-tea  and  given  three  or  four  times 
a  day.  Hector  Mackenzie  found  garlic 
most  useful  for  diminishing  the  foetor  of 
the  breath,  and  recommends  in  the  case 
of  children  the  syrup  of  garlic  of  the 
United  States  Pharmacopoeia.  A  drachm 
of  this  may  be  given  to  a  child  three 
times  a  day  with  an  equal  amount  of 
syrup  of  Tolu.  For  an  adult  2  or  3 
grains  of  powdered  garlic  may  be  given 
in  a  cachet,  or  2  to  4  drachms  of  the 
syrup. 

The  balsams  also  possess  curative 
properties,  but  do  not  reach  the  diseased 
areas  when  applied  by  means  of  the 
atomizer. 

Molle  has  observed  rapid  improve- 
ment, amounting  practically  to  cure,  in 
children  by  the  use  of  the  following 
mixture : — 

I^   Eucalyptol,  10  parts. 

Creasote,  25  parts. 

Tincture  of  benzoin,  50  parts. 

Copaiba,  80  parts. 

Oil  of  sweet  almonds,  enough  to 
make  200  parts. 
Thirty  drops  of  this  mixture  are  in- 
jected into  the  rectum,  in  a  little  milk, 
and  the  amoimt  is  gradually  increased  to 
one  or  two  teaspoonfuls.  One  injection 
daily  is  suiScient.  The  child  experiences 
a  temporary  burning  sensation  to  which 
it  rapidly  grows  accustomed.  If  this 
treatment  is  persisted  in  for  months,  all 
the  symptoms  are  said  to  diminish,  and 
the  general  condition  is  correspondingly 
improved,  even  proceeding  to  a  cure. 


BRONCHIECTASIS.     TREATMKNT. 


639 


The  ordinary  commercial  coal-tar 
creasote  is  highly  recommended  by 
Arnold  Chaplin,  the  aim  being  to  empty 
the  dilated  tubes  of  the  foetid  material 
and  to  prevent  their  becoming  filled 
again.  According  to  this  author,  and 
the  argument  is  sustained  by  the  excel- 
lent results  obtained,  in  order  to  fulfill 
the  qualifications  given  above,  a  drug  is 
needed  which,  while  it  is  strongly  anti- 
septic, must  at  the  same  time  be  pungent 
and  acrid  enough  to  induce  violent  ex- 
pulsive efforts.  These  conditions  are, 
according  to  Chaplin,  fulfilled  by  the 
common  commercial  coal-tar  creasote. 
The  mode  of  application  is  as  follows: 
A  room  about  seven  feet  square  by  seven 
feet  high  must  be  obtained,  and  this 
must  be  rendered  tolerably  air-tight.  It 
is  well  to  have  the  room  on  the  top  of 
the  house,  or  away  from  it,  as  there  will 
be  less  chance  of  the  vapors  generated 
from  the  creasote  causing  annoyance  to 
those  living  in  the  house.  In  the  centre 
of  this  room  a  small  stand  about  1  ^/j 
feet  high  is  placed,  and  on  this  an  ordi- 
nary spirit-lamp  which  admits  of  being 
raised  or  lowered.  Over  the  spirit-lamp, 
on  a  tripod,  an  enameled-tin  dish  is 
placed,  and  into  this  is  poured  about 
half  a  pint  of  the  coal-tar  creasote.  The 
creasote  is  heated  until  the  dense  pun- 
gent fumes  are  given  off.  The  patient, 
clothed  in  an  old  dressing-gown,  is 
placed  in  the  room  as  soon  as  the  lamp 
is  lighted.  As  soon  as  the  fumes  begin 
to  come  off,  an  urgent  desire  to  cough 
comes  on,  and  soon  the  cough  becomes 
more  or  less  incessant,  and  attended  with 
the  expulsion  of  large  quantities  of 
phlegm.  After  the  sitting  has  lasted 
from  a  half  to  one  hour  the  patient  may 
leave  the  room,  and  wait  until  the  next 
day  before  taking  another  sitting.  This 
should  go  on  steadily  from  day  to  day 
for  two  months.     For  the  first  day  or 


two  not  much  benefit  will  be  noticed, 
but  very  soon  the  expectoration  becomes 
reduced  and  the  odor  less  disgusting, 
and  before  very  long  the  patient,  who 
before  was  unbearable,  is  able  to  mix 
with  his  friends,  and,  unless  he  has  a 
fit  of  coughing,  his  breath  is  quite  free 
from  smell.  After  two  months  the  pa- 
tient seems  practically  cured,  but  he 
must  take  a  sitting  at  least  three  times 
a  week  if  he  will  keep  his  expectoration 
free  from  odor.  With  the  cessation  of 
the  foetor  comes  increased  appetite  and 
strength. 

Children  do  not  bear  the  treatment 
well,  and  the  benefit  to  them  is  not 
nearly  so  marked.  The  method  is  an 
unpleasant  one,  however,  and  it  requires 
all  the  persuasive  powers  of  the  physician 
to  keep  the  patient  up  to  the  necessity 
of  going  on  with  the  application  of  the 
drug;  but  after  a  few  sittings  patients 
generally  become  used  to  it.  Secondly, 
the  fumes  of  the  creasote  produce  run- 
ning and  smarting  of  the  eyes  and  nose; 
but  this  can  be  prevented  by  introducing 
two  plugs  of  cotton-wool  into  the  nos- 
trils and  covering  the  eyes  with  a  pair 
of  glasses  rimmed  round  with  India  rub- 
ber. Beyond  these  there  are  no  draw- 
backs to  the  treatment,  and  it  can  con- 
fidently be  recommended  as  likely  to 
improve  the  condition  of  the  patient  if 
persevered  in  for  sufficient  length  of 
time. 

Creasote  found  of  mucli  value,  admin- 
istered in  the  form  of  carbonate  of  crea- 
sote, ^/j  drachm  three  times  a  day. 
Price  Brown  (Canadian  Practitioner, 
Feb.,  '96). 

Surgical  measures  have  been  resorted 
to  with  the  view  of  reaching,  by  ex- 
ternal incision  and  draining,  the  cavi- 
ties containing  foetid  accumulations. 
But  the  fact  that  the  latter  are  very 
rarely  localized  within  a  restricted  area 


640 


BRONCHIECTASIS. 


BRONCHITIS. 


at  once  condemns  so  severe  a  remedy, 
that  involves  complications,  especially 
pneumonia,  which  may  soon  cause  the 
patient's  death.  The  only  kind  of  case 
in  which  it  might  in  the  least  be  war- 
rantable is  where  the  presence  of  but  a 
single  bronchiectasic  cavity  can  abso- 
lutely be  established  by  physical  exami- 
nation, and  even  then  only  when  it  is 
near  the  surface. 

Two  cases  of  bronchiectasis  in  which 
great  relief  was  given  during  the  par- 
oxysms, and  some  more  permanent  bene- 
fit afforded,  by  placing  the  patient  lying 
down  on  the  bed  the  foot  of  which  was 
raised  twelve  or  fourteen  inches.  The 
immediate  result  in  both  cases  was  a 
great  sense  of  relief,  a  diminution  in  the 
frequency  and  severity  of  the  cough, 
a  lessening  of  the  sputum,  a  complete 
cessation  of  the  gush  of  expectoration, 
and  presumably  the  liberation  of  the 
affected  pulmonary  areas  from  entan- 
gling slime  and  from  any  further  plug- 
ging with  muco-pus.  The  postural 
method  is  also  useful  in  contributing  to 
the  comfort  and  relief  of  patients  suffer- 
ing from  general  catarrhal  affections 
with  tenacious  mucus,  as  well  as  in  the 
later  stages  of  pulmonary  excavation  in 
phthisis.  William  Ewart  (Lancet,  July 
13,  1901). 

In  treating  bronchiectasis  the  meth- 
ods placed  in  the  order  of  their  effi- 
ciency may  be  classified,  as  follows:  — 

1.  Inhalations  of  volatilized  antisep- 
tics: (a)  creasote  vapor-baths ;  (bj  in- 
halations of  creasote,  oil  of  peppermint, 
eucalytus,  etc. 

2.  Subcutaneous  and  intravenous  in- 
jections of  antiseptic  fluids. 

3.  Internal  medication. 

4.  Surgical  treatment  (incision  and 
drainage). 

The  most  successful  means  of  reliev- 
ing the  foetor,  and  occasionally,  but  by 
no  means  always,  of  lessening  the 
amount  of  the  expectoration,  is  the  in- 
halation under  certain  conditions  of 
crude  creasote-vapor,  as  originally  sug- 
gested by  Dr.  Arnold  Chaplin.  It  is 
necessary  to  carry  out  this  treatment 
systematically  and  thorovighly. 


The  details  are  as  follows:  A  small 
room,  free  of  any  furniture  except  that 
of  the  simplest  kind,  and  without  hang- 
ings, is  selected.  It  should  have  good 
ventilation  provided  mainly  by  means 
of  a  small  fireplace,  or  in  summer  by 
means  of  Tobin's  tubes.  The  patient 
should  be  provided  ^vith  a  comfortable 
wooden  chair.  On  a  small  table  is  ar- 
ranged an  evaporating  dish  of  the 
capacity  of  about  half  a  pint,  heated 
over  a  spirit-lamp.  It  is  advisable  not 
to  consent  to  the  use  of  a  Bunsen  gas- 
burner.  Into  the  evaporating  basin  is 
put  commercial  creasote. 

The  creasote  is  slowly  vaporized,  and 
as  the  dense  fumes  begin  to  rise  the 
patient  commences  to  cough,  and  not 
only  are  the  tubes  cleared  of  the  offen- 
sive secretions,  but  the  deep  inspirations 
which  follow  serve  to  draw  the  crea- 
sote-vapor into  the  smaller  bronchioles, 
bringing  it  into  immediate  contact  with 
the  decomposing  pus  in  the  dilated 
tubes.  A  twofold  object  is  thus 
effected:  the  cleansing  of  the  tubes  and 
the  evacuation  of  their  contents.  It  is 
in  this  combination  that  the  creasote 
vapor-bath  is  more  effectual  than  any 
other  form  of  treatment.  Until  the 
patient  becomes  more  or  less  accus- 
tomed to  them,  the  fimies,  which  are 
very  penetrating,  cause  a  considerable 
amount  of  distress,  and  it  is  mainly 
the  great  benefit  which  is  derived  from 
the  treatment  which  encourages  pa- 
tients to  continue  it. 

The  volatilization  of  a  large  amount 
of  crude  creasote  makes  everything  in 
a  mess,  and  the  patient's  clothes  must 
be  protected,  and  no  ornaments  or 
pictures  must  be  left  upon  the  walls. 
T.  D.  Acland  (Practitioner,  April,  1902). 

Chahles  E.  de  M.  Sajous, 

Philadelphia. 

BKONCHITIS. 

Definition.  —  An  inflammation  of  the 
mucous  membrane  of  the  bronchi,  usu- 
ally including  the  trachea.  It  occurs  as 
a  primary  affection  or  as  a  feature  of 
many  general  diseases,  especially  the 
exanthemata. 


BRONCHITIS.     ACUTE.     SYMPTOMS. 


641 


Varieties. — Bronchitis  may  be  sub- 
divided into  four  distinct  forms:  the 
acute,  in  which  the  inflammatory  process 
is  more  or  less  severe,  but  of  limited 
duration;  the  chronic,  in  which  organic 
changes  in  the  mucous  membrane  main- 
tain the  activity  of  the  final  stage  of  the 
previous  form;  the  foetid,  which  differs 
from  the  two  previous  forms  by  the 
foetid  odor  of  the  sputa;  the  fibrinous, 
or  plastic,  which  is  characterized  by  the 
presence  of  pseudomembranous  easts 
formed  in  the  bronchi. 

Capillary  bronchitis,  so-called,  being 
in  reality  a  form  of  catarrhal  pneumonia, 
will  be  treated  under  Pneumonia. 

Acute  Bronchitis. 

Symptoms. — The  course  of  acute  pri- 
mary bronchitis  is  fairly  uniform.  After 
exposure  to  cold,  wet,  or,  oftentimes,  to 
a  close  atmosphere,  there  is  a  feeling  of 
malaise  accompanied  by  chilly  sensa- 
tions or,  more  rarely,  a  pronounced  chill. 
Within  a  short  time  slight  fever  devel- 
ops, and  coincidentally  with  this  or 
shortly  afterward  a  feeling  of  constric- 
tion or  oppression  beneath  the  sternum, 
which  is  intensified  by  deep  inspiration. 

Cough  soon  appears,  but  is  at  first  dry, 
harassing,  and  not  productive  of  relief. 
The  temperature  is  usually  elevated  by 
a  few  degrees,  but  in  children  may  rap- 
idly rise  to  102°  or  103°  F.  In  the 
course  of  twenty-four  hours  the  cough 
increases  in  severity,  and  by  the  end  of 
that  time  is  accompanied  by  the  expec- 
toration of  a  small  quantity  of  glairy  mu- 
cus produced  only  by  inordinate  effort. 
Gradually  the  cough  becomes  softer,  the 
expectoration  increases  in  amount  and 
becomes  opaque  and  finally  yellowish. 
As  expectoration  increases  the  substernal 
discomfort  lessens,  the  general  feeling 
of  illness  diminishes,  and  the  tempera- 
ture falls  to  almost,  if  not  quite,  the 
normal  point.    After  three  or  four  days 

1- 


(sometimes  sooner)  the  only  symptoms 
remaining  are  frequent  cough  and  a 
rather  copious  expectoration  of  yellow- 
ish-white muco-purulent  material  occa- 
sionally appearing  as  distinct  clumps. 
The  cough  gradually  lessens,  the  expec- 
toration becomes  less  profuse,  until 
finally  the  patient  recovers  completely 
after  the  course  of  a  week  or  ten  days. 

In  cases  running  a  short  course  the 
mucous  membrane  probably  becomes  at 
once  normal,  although  one  attack  of 
bronchitis  frequently  leaves  behind  it  a 
certain  susceptibility. 

In  children  the  initial  general  symp- 
toms are  more  severe,  the  temperature 
elevation  is  greater,  there  is  no  visible 
expectoration  until  the  fourth  or  fifth 
year,  and  vomiting  is  more  frequent. 
Catarrhal  pneumonia  and  atelectasis  are 
frequent  complications  which  may  cause 
a  fatal  termination. 

In  the  aged  there  is  but  little  general 
disturbance  at  the  outset,  but  the  disease 
is  apt  to  assume  a  subacute  or  chronic 
course,  or  the  disease  may  end  fatally 
in  those  enfeebled  by  advanced  years  or 
structural  disease  in  other  parts. 

Physical  examination  in  the  early 
stages  may  show  nothing  or  merely  a  few 
scattered  sibilant  rales.  The  respirations 
are  slightly  increased  in  frequency  and 
a  little  more  shallow  than  in  health,  ex- 
cept in  infants,  where  the  respiratory 
rate  may  be  greatly  increased.  In  the 
course  of  the  first  twenty-four  hours 
there  develop  sibilant  rales  over  areas  on 
both  sides  of  the  chest,  but  especially  in 
the  spinal  gutter.  These  rales  rapidly 
shift  their  position  and  may  be  either 
produced  or  dissipated  by  the  act  of 
coughing.  As  the  swelling  of  the  mu- 
cous membrane  increases  or  mucus  is 
secreted  in  sufficient  amount  to  mate- 
rially alter  the  calibre  of  the  larger  tubes, 
sonorous  rales  appear.    The  out-pouring 


642 


BRONCHITIS.    ACUTE.    DIAGNOSIS.    ETIOLOGY.    PATHOLOGY. 


of  mucus  in  larger  amounts  causes  the 
appearance  of  moist,  mucous  rales  in  ad- 
dition. In  the  absence  of  involvement 
of  the  pulmonary  parenchyma  percussion 
gives  negative  results.  Palpation  fre- 
quently, especially  in  children,  reveals 
a  coarse  fremitiis,  which  may  be  found  to 
disappear  after  free  expectoration  or 
vomiting.  The  occurrence  of  complicat- 
ing pneiimonia  or  atelectasis  produces 
the  signs  peculiar  to  those  conditions. 

Diagnosis. — The  diagnosis  presents  no 
difficulty  except  in  the  determination  of 
the  primary  or  secondary  origin  of  the 
trouble.  The  chief  difficulty  occurs  ip 
children,  where  time  alone  may  be  able 
to  decide  the  question  as  to  whether  the 
bronchitis  is  "simple"  or  is  the  premoni- 
tory stage  of  pertussis  or  measles. 

Etiology. — The  causes  may  be  classi- 
fied as  mechanical,  chemical,  infectious, 
and  toxic.  Of  mechanical  causes  are  the 
inhalation  of  dust,  particles  of  food,  etc.; 
of  the  chemical  as  the  inhalation  of  irri- 
tating gases  (such  as  chlorine);  of  in- 
fective, that  occurring  in  the  course  of 
measles  is  the  most  marked.  Among  the 
toxic  causes  the  poison  of  ursemia  and 
possibly  that  of  some  of  the  infections 
must  be  included,  the  latter  upon  the 
theory  that  the  inflammation  is  produced 
by  the  excretion  of  toxins  by  the  respira- 
tory tract. 

Exposure  to  cold  and  damp  is  an  etio- 
logical factor  probably  acting  by  lower- 
ing bodily  resistance  and  allowing  the 
invasion  of  the  mucous  membrane  by 
micro-organisms  constantly  present,  but 
under  ordinary  circumstances  impotent. 
The  possibility  of  bronchitis  being 
produced  by  the  elimination  through 
the  respiratory  passages  of  materials  or- 
dinarily passed  out  through  the  other 
emunctories  cannot  be  certainly  cast 
aside.    Bronchitis  has  also  been  ascribed 


to  the  effects  of  ether,  employed  as  an 
ansesthetic. 

The  infective  nature  of  acute  bron- 
chitis has  not  hitherto  been  generally 
accepted.  In  health  the  great  majority 
of  observers  find  the  lower  air-passages 
sterile,  the  bacteria  being  withdrawn 
into  the  upper  air-passages,  chiefly  by  the 
nasal  mucous  membrane  and  the  adenoid 
tissue  of  the  pharynx.  Jundell,  for  ex- 
ample, examining  the  tracheas  by  means 
of  a  special  instrument,  in  forty-three 
people  found  it  either  quite  sterile  or 
else  containing  only  scanty  transitory 
bacteria. 

Personal  cases  grouped  in  two  sec- 
tions:— 

Cases    of   bronchitis    without 

pneumonia   27 

Cases  of  bronchitis  with  pneu- 
monia   22 

In  all  but  6  pathogenetic  bacteria  were 
found  in  great  numbers. 

Of  these,  those  most  frequently  pres- 
ent were  streptococcus  pyogenes — found 
in  2  cases  in  pure  culture,  in  19  in 
association  with  other  pathogenetic  bac- 
teria; diplococcus  pneumoniae — found  in 
15  eases  of  pure  bronchitis  and  in  8 
of  bronchitis  with  pneumonia,  and  in 
these  23  cases  in  large  numbers  in  all 
but  2,  never  in  healthy  bronchi;  in- 
fluenza bacillus — found  in  17  out  of  49, 
never  alone. 

Acute  bronchitis  is  an  infective   dis- 
ease, not  due,  however,  to  any  specific 
organism;   it  is  usually  a  mixed  infec- 
tion, the  most  important  agents  being 
the     streptococcus     pyogenes     and     the 
diplococcus  pneumoniae.      The  infiuenza 
bacillus  not  infrequently  produces  bron- 
chitis   apart    from    influenza.      Eitchie 
(Jour,  of  Path,  and  Bact. ;  Practitioner, 
May,  1901). 
Bronchitis  is  frequently  caused  by  the 
extension   of   diphtheria   and   erysipelas 
from  the  upper  tract,  but  in  that  case 
cannot   be   considered   as   simple   bron- 
chitis. 

Pathology. — The  mucous  membrane 
is  injected,  of  a  bright-red  color,  is  thick- 
ened, and  thrown  into  longitudinal  folds. 
The  surface  is  usually  covered  with  more 


BRONCHITIS.     ACUTE.     PKOGXOSiy.     TKEATMENT. 


643 


or  less  mucus  or  muco-pus.  On  section 
there  is  found  leucocytic  infiltration  of 
the  deeper  layers.  The  epithelial  layer 
shows  active  proliferation  of  the  cells; 
goblet-cells  are  numerous  and  greatly 
distended;  the  cells  of  the  mucous  glands 
are  swelled  and  granular;  and  the  cili- 
ated epithelial  cells  are  seen  to  be  shed 
in  large  numbers. 

The  streptococcus  bacillus  predomi- 
nated in  all  eases  of  bronchitis  in  influ- 
enza. In  quite  a  number,  and  some  of 
the  worst,  it  was  the  only  bacterium 
found  in  the  expectoration.  In  23  cases 
the  streptococcus  was  associated  with 
staphylococci  alone;  in  3  cases  strepto- 
cocci, staphylococci,  and  the  influenza 
bacillus  were  associated;  in  27  cases  the 
streptococcus  alone  was  found.  The  in- 
fluenza bacillus  disappeared  after  a 
short  time,  and  was  replaced  by  the 
streptococcus.  F.  Forchheimer  (Med. 
News,  June  1,  1901). 

Many  instances  observed  of  localized 
bronchitis  in  which  the  sputum  is 
crowded  with  diplocoeeus  pneumoniae. 
This  suggests  that  these  micro-organ- 
isms are  the  essential  causal  factor  in 
a  large  proportion  of  such  eases.  This 
germ  tends  to  affect  localized  areas  in 
one  or  more  pulmonary  lobes  and 
usually  runs  a  benign  course.  There  is 
also  a  tendency  of  recurrent  attacks 
to  implicate  the  same  area  again  and 
again.  P.  W.  Williams  {Bristol  Med.- 
Chir.  Jour.,  June,  1902). 

Prognosis. — In  patients  beyond  the  age 
of  infancy  and  in  those  not  debilitated 
by  senility  or  serious  organic  disease  re- 
covery invariably  occurs.  In  young  chil- 
dren recovery  is  the  rule;  but  the  dis- 
ease is  of  more  gravity  than  in  older 
children  and  adults,  this  gravity  increas- 
ing inversely  as  the  strength  and  age  of 
the  child.  The  chief  danger  in  older 
children  and  in  adults  lies  in  the  tend- 
ency to  recurrence  and  consequent  per- 
manent change  in  the  mucous  mem- 
brane. 

Treatment. — Treatment   varies   some- 


what with  the  age  of  the  patient.  A 
few  general  directions  apply  to  all  ages. 
Equalization  of  the  circulation  and  stim- 
ulation of  all  lagging  emunctories  are 
important  early  measures.  In  all  cases 
purity  of  air,  equable  room-temperature 
(69°  to  70°  F.),  and  a  slight  excess  of 
moisture  in  the  air  are  essential. 

In  young  infants  the  child  should  be 
clad  rather  more  warmly  than  ordinarily, 
a  cotton  or  woolen  jacket  should  be  ap- 
plied, and  the  chest  should  be  rubbed 
twice  daily  with  camphorated  oil  or  a 
mixture  of  equal  parts  of  olive-oil  and 
amber-oil  or  turpentine.  A  croup-ket- 
tle, to  the  water  in  which  has  been 
added  compound  tincture  of  benzoin  (1 
fluidrachm  to  1  pint)  should  be  em- 
ployed for  ten  or  fifteen  minutes  every 
hour  or  two,  and  in  winter  a  broad, 
shallow  pan  of  water  should  be  kept  in 
front  of  the  source  of  heat  in  order,  by 
its  evaporation,  to  moisten  the  air  of  the 
room.  Morrell  has  observed  great  bene- 
fit from  inhalations  of  warm  vapor  of 
wine  of  ipecacuanha,  ten  minutes  at  a 
time,  three  or  four  times  a  day. 

The  hot,  dry  chamber  of  the  Turkish 

bath    has   been  the   means   of   aborting 

attacks    of    bronchitis,    and    deserves    a 

trial ;  the  patient  to  be  driven  in  a  closed 

vehicle  to  and  from  the  bath,  and  with 

moiith  and  nose  protected  with  woolen 

comforter.     I   am   fully  persuaded  that 

the    indiscriminate    recommendation    of 

the   bronchitis-kettle    is    a   great   error; 

it  has  contributed  to  the  deaths  of  not  a 

few  to  my  own  kno^Yledge.     Alexander 

Duke   (Med.  Press  and  Circular,  Feb.  3, 

'97). 

Ordinarily  in  the  early  stage  a  simple 

fever-mixture    with   the    addition    of   a 

small  quantity  of  ipecac  will  be  all  that 

is  required.    Of  the  febrifuges  the  citrate 

of  potash  with  or  without  the  addition 

of  small  doses  of  tincture  of  aconite  in 

accordance  with  the  fever  and  cardiac 

excitement  will  be  found  useful  and  sim- 


644 


BKONCHITIS.     ACUTE.     TREATMENT. 


pie.  After  the  formation  of  mucus  has 
started  and  the  fever  has  subsided  the 
chloride  of  ammonium,  in  doses  of  ^/^ 
to  1  grain,  should  replace  the  fever-mixt- 
ure. 

Ordinarily  no  further  medication  is 
required  except  for  the  use  of  mild  laxa- 
tives to  keep  the  bowels  thoroughly 
opened.  In  removing  the  extra  covering 
on  the  chest  care  is  to  be  taken  that  the 
change  be  not  made  too  rapidly,  but  that 
small  portions  should  be  taken  away  at 
a  time.  If  at  any  time  marked  oppres- 
sion of  breathing  occurs  from  accumula- 
tion of  mucus,  the  production  of  vomit- 
ing by  a  full  dose  of  ipecac  will  cause 
prompt  clearing  of  the  tubes.  In  feeble 
children  stimulants  may  be  required,  and 
where  the  heart's  action  is  weak  the  car- 
bonate or  aromatic  spirit  of  ammonium 
may,  with  advantage,  be  used  instead  of 
the  chloride. 

Apomorphine,  freshly  compounded  in 
acidulated  mixture,  is  the  best  of  all 
relaxing  expectorants.  In  ^Ao-grain 
doses,  at  two  or  three  hours'  inteiwals, 
rarely  fails  to  cause  a  free  sero-mucous 
flow  in  twelve  to  thirty-six  hours.  Rest 
is  an  essential  adjuvant.  Codeine  sul- 
phate in  Vo-grain  doses,  given  independ- 
ently, is  the  best  sedative.  Thomas 
Hubbard  (N.  Y.  Med.  Jour.,  July  18, 
'96). 

In  acute  bronchitis  of  adults  a  com- 
bination of  acetate  of  ammonium,  spirit 
of  nitrous  ether,  and  ipecacuanha  or 
antimony  is  commonly  used,  and  no  bet- 
ter combination  can  be  employed.  But 
an  error  is  often  made  with  regard  to  the 
dose  of  two  of  these  substances.  One 
should  begin  with  doses  of  3  drachms  of 
the  acetate  of  ammonium,  and  increase 
the  amount  to  6  drachms  if  the  skin  does 
not  act  freely.  Spirit  of  nitrous  ether 
may  possibly  act  in  Vrdrachm  doses,  but 
in  doses  of  1  to  2  drachms,  especially 
when  repeated  at  short  intervals,  it  has 
commonly  a  very  distinct  effect  as  a  di- 
aphoretic. D.  J.  Leech  (Practitioner, 
May,  '98). 


In  older  children  and  in  adults  a  pre- 
liminary hot  foot-bath,  to  equalize  the 
circulation  and  start  the  emunctories, 
is  of  value.  The  application  of  mustard 
poultices  or  turpentine  stupes  to  the 
chest  certainly  gives  relief  and  probably 
hastens  cure.  The  use  of  a  cotton  or 
woolen  jacket  is  not  so  important  as  in 
infants,  but  is  of  value.  In  those  beyond 
the  age  of  infancy  ammonia  salts  can  be 
used  earlier  in  the  disease,  the  chloride 
acting  especially  well  in  combination 
with  compound  licorice  mixture.  Usu- 
ally no  other  medicine,  save  possibly 
laxatives,  is  required  unless  the  latter 
part  of  the  attack  is  prolonged,  in  which 
case  small  and  frequently  repeated  doses 
of  the  oil  of  eucalyptus,  gaultheria,  or 
copaiba  may  be  given  in  capsule. 

In  the  aged  it  is  important  to  sustain 
the  general  strength  and  especially  to 
watch  the  condition  of  the  right  heart. 
Stimulants  are  usually  necessary;  and 
it  is  important  to  change  the  patient's 
position  at  short  intervals  in  order  to 
facilitate  expectoration  and  to  avoid  the 
effects  of  gravity  in  causing  congestion 
or  atelectasis  of  dependent  parts  of  the 
lung.  Many  expectorant  drugs  other 
than  those  mentioned  above  are  em- 
ployed, but  it  is  a  question  whether  their 
action  upon  digestion  does  not  offset  any 
possible  good  effect  upon  the  bronchitis. 

The  use  of  oxygen  in  inhalation  is 
sometimes  objected  to  on  the  ground  that 
it  is  not  a  really  curative  agent.  This 
is  true,  but  the  inference  that  it  is  not 
worth  giving  is  believed  fallacious.  It 
does  often  remove  cyanosis,  and  a  con- 
tinuous condition  of  cyanosis  must  be 
an  evil.  It  is  probable  that  the  inhala- 
tion of  oxygen  is  generally  commenced 
too  late.  Belief  that  its  early  use  pre- 
vents the  advent  of  that  pronounced 
cyanosis  so  often  seen,  and  which,  when 
it  is  once  established,  may  be  only 
slightly  benefited  by  oxygen. 

It   thus   gives   patients   an    additional 


BRONCHITIS.  CHRONIC.  SYMPTOMS. 


645 


chance  of  life,  and,  furthemiore,  in  most 
cases  it  gives  marked  relief.  If  we  ob- 
jected to  give  drugs  in  ailments  unless 
they  had  a  direct  curative  influence,  our 
use  of  the  pharmacopoeial  remedies  would 
be  vei-j'  limited.  D.  J.  Leech  (Praeti 
tioner,  May,  '98). 

Verba  santa  is  extremely  efficacious 
in  the  treatment  of  the  second  stage  of 
bronchitis;  it  seems  to  diminish  the 
watei'y  and  mucous  constituents  of  the 
phlegm  proportionately,  so  that  this  does 
not  become  more  difficult  of  expectora- 
tion. The  dose  is  15  to  45  minims  of 
the  liquid  extract.  It  forms  a  somewhat 
muddy  mixture  with  water,  but  the 
addition  of  ammonium  carbonate  or 
bicarbonate  of  soda  makes  it  clearer. 
Bronchial  spasm  in  the  course  of  the 
second  stage  of  bronchitis  is  best  treated 
with  caflfeine  or  iodide  of  potassium. 
F.  H.  Edgeworth  (Bristol  j\Ied.-Chir. 
Jour.,  Sept.,  '99). 

In  children  true  asthma  is  very  rare, 
and  chronic  bronchitis  does  not  occur. 
Bronchitis  often  recurs,  or  may  be  pro- 
longed, but  it  never  becomes  chronic. 
Emphysematous  bronchitis  is  the  most 
common  form  in  children.  There  is  al- 
ways some  dj'spnoea,  yet  never  marked 
asthmatic  paroxysms.  AVhen  a  child 
has  many  attacks,  his  bronchi  become 
distended  from  loss  of  elasticity.  This 
bronchitis  is  commonly  observed  with 
the  infectious  diseases,  and  in  rachitic, 
lithEemic,  or  tubercular  children.  From 
5  to  15  drops  of  I-per-cent.  solution  of 
iodide  of  arsenic  thrice  daily,  with 
meals,  has  proved  valuable  in  this  con- 
dition. R.  Saint-Philippe  (Jour,  de  Med. 
de  Bordeaux,  May  5,  1901). 

Arsenic  iodide  is  the  best  remedy  in 
that  form  of  infectious  bronchitis  which 
occurs  in  scrofulous  children  after 
grippe,  measles,  or  whooping-cough. 
■\Vhen  taken  with  food  it  is  said  to  be 
practically  tasteless,  easily  digested,  and 
well  borne.  The  following  formula  is 
used: — 

B  Arsenic     iodide,     0.3     gramme     (o 
grains). 
Distilled   water,   .30.0   grammes    (1 
fluidounce). 

Dissolve  without  the  aid  of  heat. 

Five  drops  of  this  solution  are  given 


in  a  glassful  of  milk  with  each 
meal,  the  dose  being  increased  by  1  drop 
morning  and  evening  imtil  15  or  even 
iiO  drops  are  being  taken  as  a  dose. 
Ihe  maximum  dose  is  given  for  about 
a  month,  then  gradually  reduced  to  5 
drops,  and  this  quantity  is  continued 
for  a  week,  and  then  again  increased 
as  before.  Saint-Philippe  (.Jour,  des 
Praticiens,  xvi.  No.  16,  1902). 
The  following  combination  is  useful:  — 

Syr.  scillee,  I  ounce. 

Ext.  lobelife  fld.,  I  drachm. 

linct.  opii,  2  y.  drachms. 

ijxt.  ipecac  fld.,  15  drops. 

Syr.  pruni  Virg.,  1  V,  ounces. 

Syr.  picis  liq.,  q.  s.  ad  4  ounces. 
M.    Sig. :     One    teaspoonful    in   water 
four   times   a  day.     (Jour.  Amer.   Med. 
Assoc,  .Jan.  31,  1903.) 

Chronic  Bronchitis. 

Symptoms.  —  The  onset  of  chronic 
bronchitis  is  usually  insidious.  It  may 
follow  immediately  upon  an  acute  at- 
tack which  fails  to  subside  or  it  may  be 
gradual  in  its  beginning,  as  in  cases  re- 
sulting from  the  long-continued  inhala- 
tion of  irritating  material,  such  as  me- 
tallic or  crystalline  dust  or  chemical 
vapors.  Cough  is  the  most  prominent 
symptom.  It  is  usually  worse  in  the 
morning  and  after  meals,  but  may  give 
most  trouble  at  night.  It  is  usually  ac- 
companied by  free  expectoration  of  thick 
muco-purulent  material  of  white,  yel- 
lowish-white, or  green  color,  at  times 
twanged  or  streaked  with  blood.  In  a 
small  proportion  of  cases  there  is  no  ex- 
pectoration (dry  bronchitis). 

Cough  and  expectoration  are  for  a 
long  time  the  only  symptoms,  but  in  ad- 
vanced cases  (especially  in  elderly  peo- 
ple) the  right  heart  feels  the  strain  of 
overcoming  the  increased  tension  in  the 
pulmonary  circuit,  becoming  dilated  and 
causing  circulatory  embarrassment  in  the 
other  organs  (stomach,  liver,  and  kid- 
neys). Pulmonary  emphysema,  bron- 
chiectasis,   and    asthma    are    the    other 


646 


BRONCHITIS.     CHRONIC.     ETIOLOGY.     PATHOLOGY. 


sequelas  encountered.  Exacerbations  are 
readily  excited,  obstinate,  and  prone  to 
leave  increased  organic  change. 

Bronchorrhoea,  so-called,  designates 
but  an  exaggerated  flow  of  the  bron- 
chial secretions.  These  may  be  more 
or  less  watery,  mucoid,  or  muco-purulent. 
As  much  as  six  pints  have  been  expec- 
torated in  one  day  by  a  single  patient. 

On  physical  examination  but  little 
may  be  found  in  the  "dry"  form.  Other- 
wise the  findings  will  depend  upon  the 
extent  and  duration  of  the  disease  and  the 
presence  or  absence  of  its  consequences 
upon  the  remainder  of  the  respiratory 
apparatus.  In  uncomplicated  cases  in- 
spection gives  no  result.  On  palpation  a 
strong  fremitus  may  be  felt  from  the 
vibration  of  mucus  within  the  air-tubes. 
The  bubbling  and  rattling  of  this  mate- 
rial may  be  audible  at  a  distance.  On 
percussion  there  is  no  change  unless  the 
pulmonary  structure  is  already  involved 
or  bronchiectases  have  formed.  On  aus- 
cultation loud  bubbling  and  mucous  or 
sibilant  and  sonorous  rales  are  heard, 
which  shift  their  position  or  may  be  en- 
tirely dissipated  by  cough.  Sometimes 
the  breath-sounds  over  one  portion  of 
the  lung  may  be  feeble  for  a  time  from 
partial  obstruction  by  mucus  to  the  en- 
trance of  air.  The  diagnosis  presents 
no  difficulties  if  careful  examination  of 
the  chest  and  of  the  sputum  be  made. 

Etiology. — The  chronic  form  is  pro- 
duced by  the  same  causes  as  those  men- 
tioned under  acute  bronchitis  acting  for 
a  longer  time  or  frequently  repeated. 
Insanitary  surroundings,  debility,  and 
possibly  inherited  vulnerability  are 
strong  predisposing  factors.  Gout  would 
seem  also  to  be  to  some  extent  a  pre- 
disposing cause.  Mitral  disease  and 
enlargement  of  the  tracheo-bronchial 
glands  are  contributing  conditions  be- 
cause of  their  causing  interference  with 


the  return-flow  of  blood  and  lymph  from 
the  bronchial  tree. 

Chronic  bronchitis  is  very  apt  to  be 
found  in  the  two  extremes  of  age.  In 
children  it  may  be  associated  with  ad- 
enoid vegetations  and  enlarged  lymphat-, 
ics  and  hypertrophied  tonsils.  Among 
older  persons  the  more  common  causes 
of  chronic  bronchitis,  aside  from  lym- 
phatic and  scrofulous  tendencies,  are  the 
gouty  diathesis,  insuilicient  action  of  the 
heart,  emphysema,  and  asthma. 

Six  cases  of  bronchitis  and  bronclio- 
pneumonia  caused,  respectively,  by 
chlorine-gas,  sulphurous-acid  gas,  for- 
maldehyde, kerosene-smoke,  and  smoke 
containing  some  unknown  acid  fumes. 
In  the  first  three  cases  the  irritants  had 
only  caused  bronchitis,  while  in  the  last 
three  broncho-pneumonia  developed. 
The  writer  concludes  that  the  above 
forms  of  bronchitis  are  much  more 
painful  in  the  beginning  than  the  or- 
dinary kind.  They  are  likely  to  have 
loud,  rough,  wheezing  rales,  and,  in  the 
case  of  certain  chemicals,  fine,  moist 
ones  as  well.  This  form  of -bronchitis 
may  easily  go  on  to  a  broncho-pneu- 
monia. Hall  (Phila.  Med.  Jour.,  Dec. 
20,  1902). 

Pathology. — The  appearance  of  the 
bronchi  difl:ers  much  in  accordance  with 
the  duration  and  severity  of  the  disease. 
In  the  mildest  forms  the  mucous  mem- 
brane is  of  a  dull-red  or  slate  color, 
thickened,  and  corrugated  longitudi- 
nally. In  more  severe  or  long-standing 
cases  atrophy  of  the  mucous  membrane 
is  present  in  places;  and  this  atrophy 
may  extend  to  the  deeper  layers  of  the 
tubes.  Consequent  upon  this  atrophy 
there  is  dilatation  of  varying  degrees 
(see  Bronchiectasis).  When  all  of  the 
coats  are  involved,  infiltration  and 
fibrosis  of  the  surrounding  connective 
tissue  takes  place,  giving  rise  to  one 
variety  of  fibroid  disease  of  the  lung. 
In  elderly  people  the  cartilaginous  rings 


BRONCHITIS.     CHRONIC.    PROGNOSIS.    TREATMENT. 


647 


frequently  undergo  calcification,  render- 
ing the  tubes  rigid.  Ulceration  may  oc- 
cur, but  is  rare  unless  bronchiectasis  has 
occurred  or  there  is  tuberculous  or  syph- 
ilitic infection.  Other  organs  are  in- 
volved secondarily,  such  as  the  right 
side  of  the  heart  (hypertrophy  or  dilata- 
tion) or  the  pulmonary  structure  (em- 
physema, fibroid  disease). 

Histologically  sections  of  the  bron- 
chi show  marked  proliferation  of  the 
epithelial  layer,  or,  in  long-standing 
cases,  great  denudation  thereof.  New 
formation  of  connective  tissue  within 
the  tissue  proper  of  the  bronchi  and  in 
the  peribronchial  connective  tissue  is 
seen  to  an  extent  corresponding  to  the 
duration  of  the  disease.  Commensurate 
with  the  fibroid  change  in  the  walls  there 
is  atrophy  of  the  proper  cellular  ele- 
ments. 

Prognosis.  —  The  prognosis  depends 
greatly  upon  the  surroundings  and  so- 
cial condition  of  the  patient.  If  re- 
moval from  the  chief  causative  factors 
(injurious  occupations,  unfavorable  cli- 
matic conditions,  etc.)  is  possible,  the 
condition  is  curable  except  for  possibly 
some  permanent  structural  changes  in 
the  bronchial  walls.  Even  with  these 
the  patient  may  be,  to  all  intents  and 
purposes,  well.  In  the  aged,  in  those 
already  sufl'ering  from  cardiac  degenera- 
tion, or  in  cases  with  serious  structural 
changes  (bronchiectasis,  emphysema) 
the  outlook  as  to  cure  is  unfavorable, 
and  as  to  amelioration  is  doubtful. 

Treatment.  —  The  prime  factor  in 
treatment  is  the  removal  of  the  cause 
(insanitary  surroundings,  inhalation  of 
dust,  etc.).  When  the  patient  lives  in  a 
changeable  or  vigorous  climate  trans- 
plantation to  an  equable  and  mild  re- 
gion is  of  itself  often  sufficient  to  pro- 
duce cure.  Prophylactic  measures  to 
decrease  the   liability   to  exacerbations 


are  important.  The  wearing  of  woolen 
underclothing,  in  order  to  prevent 
chilling  of  the  surface;  the  practice  of 
cool  bathing  on  rising,  in  order  to  pro- 
mote vascular  tonus  of  the  skin;  the 
correction  of  nasal  and  pharyngeal 
anomalies  in  order  to  do  away  with  any 
"weak  spots"  favoring  the  "catching  of 
fresh  colds" — these  are  important  ele- 
ments in  treatment. 

At  times  treatment  of  the  bronchial 
condition  is  best  carried  out  by  treat- 
ment of  systemic  faults  or  of  an  existing 
cardiac  lesion  in  combination  with  more 
direct  treatment  of  the  bronchial  ca- 
tarrh. In  many  cases  an  important 
element  is  the  "building-up"  of  the  pa- 
tient. One  of  the  most  valuable  drugs 
is  strychnine,  which  acts  as  a  general 
tonic  and  is  particularly  valuable  in 
stimulating  the  respiratory  centre  and 
toning-up  the  muscles,  thus  enabling  the 
cough  to  be  more  efEectual.  Its  value 
in  the  aged  is  very  great. 

Expectorant  remedies  are  certainly  of 
value,  yet  it  must  be  borne  in  mind  that 
they  are  very  apt  to  upset  digestion. 
Among  them  the  ammonium  compounds 
occupy  a  leading  place.  Where  the  ex- 
pectoration is  scanty  and  the  sputum 
viscid,  the  chloride  is  to  be  used;  where 
the  right  heart  is  laboring,  the  carbon- 
ate acts  best;  when  there  is  indigestion 
and  especially  flatulent  distension  the 
aromatic  spirit  is  preferable. 

Iodide  of  potassium  is  of  great  value 
in  liquefying  the  sputum,  while  its  ab- 
sorbefacient  properties  may  possibly  di- 
minish the  hyperplasia  in  the  bronchial 
walls.  In  gouty  cases  it  is  of  particular 
benefit. 

Cases  of  bronchitis  of  many  years' 
standing  cured  with  ichthyol  given  inter- 
nally in  daily  amounts  of  not  less  than 
V=  drachm.  It  should  be  administered  in 
gluten  capsules  in  order  not  to  be  freed 


648 


BKONCPIITIS.     CHRONIC.     TREATMENT. 


in  the  stomacli.    L<;  Tanneur  (Bull.  Med., 
Jan.  24,  '99). 

Encouraged  by  the  favorable  reports 
on  the  use  of  ichthyol  in  tuberculosis, 
grippe,  etc.,  W.  B.  Jennings  (St.  Louis 
Med.  and  Surg.  Jour.)  began  to  use  the 
drug  in  the  common  form  of  bronchitis 
in  children  which  so  often  follows 
measles,  whooping-cough,  and  acute,  in- 
fectious diseases  in  general.  He  gives 
the  histories  of  eight  cases  demonstrat- 
ing the  good  effects  of  ichthyol  in  the 
above-named  conditions.  It  was  admin- 
istered in  the  following  combinations:— 
Ichthyol,  gr.  xxxii. 
Glycerini, 

Spt.  aurantii,  of  each,  3ss. 
Aquse,  ad  gij. 
The  author  gives  the  following  con- 
clusions: 1.  The  first  dose  often  causes 
nausea  and  vomiting,  but  later  the  child 
grows  inured  to  the  taste  of  ichthyol. 
2.  Children  under  one  year  of  age  do 
not  take  ichthyol  well.  3.  To  avoid  the 
unpleasant  effects  of  ichthyol  it  should 
be  given  after  meals.  4.  Increasing 
doses  are  not  necessary  for  good  results 
in  childi-en.  (Merck's  Archives,  July, 
1902.) 

Case  in  a  girl  of  13,  witn  bronchitis, 
of  six  years'  duration,  following  pertus- 
sis, accompanied  with  dyspncea,  bloody 
expectoration,    and    spasmodic,    violent 
coughing,   which   failed   to   improve   on 
any  treatment,  including  morphine,  po- 
tassium    iodide,     creasote,     belladonna, 
ipecac,     sodium    benzoate,     bromoform, 
etc.    She  grew  worse  and  had  an  attack 
of  htemoptysis.    Then  powdered  ichthyol 
was  given,  15  grains  a  day.     The  effect 
was  marvelous.     Cough  and  expectora- 
tion both  disappeared  rapidly  and  she 
quickly  recovered.     H.  de  Brun    (Jour, 
des  Praticiens,  Nov.  29,  1902). 
The  balsams  and  various  expectorant 
oils  are  of  much  value  used  by  inhala- 
tion and  internally.    By  inhalation  they 
act  directly  upon  the  mucous  membrane, 
while  when  given  internally  they  exert 
their  influence  locally  upon  their  excre- 
tion   through    the    respiratory    organs. 
The  most  useful  are  the  compound  tinct- 
ure of  benzoin  and  the  oils  of  eucalyptus, 


gaultheria,  sandal-wood,  cubebs,  and 
copaiba.  For  inhalation  these  drugs 
may  be  used  on  the  Yeo  respirator,  in 
a  croup-kettle,  or  in  a  nebulizer.  Crea- 
sote is  of  value  where  the  stomach  will 
tolerate  it.  Menthol,  used  by  inhalation, 
is  an  excellent  expectorant,  allaying  the 
violent  attacks  of  cough. 

Topical  treatment  by  direct  inhala- 
tions from  No.  65  Davidson  atomizer, 
connected  with  an  air-tank  of  about 
thirty  pounds'  pressure.  The  tip  intro- 
duced into  the  mouth  and  the  patient 
is  instructed  to  make  as  prolonged  an 
aspiration  as  possible,  to  inhale  gently 
and  repeatedly,  drawing  it  into  his 
lungs.  Formulae  found  most  useful: 
menthol,  1  to  2  per  cent.;  creasote,  1 
per  cent. ;  camphor,  '/j  to  1  per  cent. ; 
eucalyptus,  2  per  cent.;  pine-needles,  2 
per  cent.;  in  albolene  or  benzoinal. 
Average  quantity  to  be  inhaled  is  2 
drachms,  after  which  the  patients  begin 
to  gag.  Kuh  (Chicago  Med.  Recorder, 
Mar.,  '93). 

The  treatment  of  bronchitis  divides 
itself  into  modification  of  the  function 
of  the  bronchial  mucous  membrane  so 
as  to  alter  the  secretion,  and  also  with 
the  object  of  combating  congestion  to 
facilitate  expectoration,  to  calm  the 
cough,  and  to  improve  the  general 
health.  The  chief  agents  which,  after 
absorption,  are  eliminated  by  the  re- 
spiratory passages,  consist  in  greater 
part  of  balsams,  of  plants  containing 
essential  oils,  sulphur  and  its  com- 
pounds, and  the  iodides.  Of  the  first 
class  in  particular  are  tar,  balsam  of 
Tolu,  benzoin,  turpentine  and  terpine, 
eucalyptol,  and  creasote.  The  incon- 
venience attending  all  is  that  they  ex- 
ercise an  irritant  influence  upon  the 
stomach.  Copaiba,  though  rarely  em- 
ployed, nevertheless  is  found  to  be  very 
efificaeioxis. 

Turpentine  is  usually  employed  in 
capsules  holding  3  or  4  minims,  but  ter- 
pine has  qiiite  largely  taken  its  place. 
Creasote  aids  in  getting  rid  of  the  secre- 
tion, and  acts  deleteriously  upon  tu- 
bercle bacilli.  The  balsams  are  usually 
employed  by  inhalation. 


BRONCPIITIS.     FCETID.     SYMPTOMS. 


649 


Eucalyptol  may  be  prescribed  in  cap- 
sules containing  1  grain  and  given  three 
or  four  times  a  day;  it  is  preferable  to 
turpentine  as  it  is  not  so  apt  to  produce 
disturbance  of  stomach  and  kidneys. 
Lyon  (Revtie  de  Th6r.  Medico-Chir. ; 
Ther.  Gaz.,  May  15,  '97). 

In  the  treatment  of  senile  bronchitis 
strychnine  and  ammonium  carbonate  are 
in  the  first  rank.  In  acute  exacerbations 
of  chronic  bronchitis  ammonium  carbon- 
ate, in  5-  or  10-grain  doses,  given  in  2 
or  3  ounces  of  milk,  is  of  great  service. 

For  chronic  bronchitis  and  convales- 
cence from  the  acute  form,  strychnine 
sulphate,  in  from  Vio  to  V20  grain,  every 
three  to  six  hours,  not  only  does  quite 
as  much  as  the  ammonium  salt,  but,  in, 
addition,  is  a  more  powerful  stimulant 
to  the  right  heart.  To  disinfect  the  ex- 
pectoration, creasote  carbonate,  in  20- 
drop  doses,  given  in  2  ounces  of  sherry, 
repeated  every  four  hours  until  puru- 
leney  disappears,  is  effective.  Ordinary 
creasote  should  never  be  given  to  the 
aged.  AVith  copious  secretion  and  diffi- 
cult expectoration  this  is  the  drug  of 
choice.  The  use  of  opium  or  any  of  its 
alkaloids  is  most  strongly  condemned. 
Wilcox  (Amer.  Jour,  of  Med.  Sciences, 
May,  1900) . 

Eespiratory  g3'mnastics,  by  increasing 
pulmonary  capacity  and  accelerating  the 
pulmonary  blood-  and  lymph-  circula- 
tion, are  efBcient.  External  applications 
to  the  chest-wall  are  of  doubtful  value  in 
the  absence  of  acute  exacerbations  and 
of  pulmonary  or  pleural  involvement. 
Systematic  daily  practice  of  full,  deep 
inhalations  of  pure  atmospheric  air,  and 
the  judicious  exercise  of  the  deep  mus- 
cles of  the  chest,  are  of  great  advantage. 
(Cassell.) 

In  bronchitis,  as  in  the  case  of  collec- 
tions of  pus,  the  object  of  treatment  is 
to  facilitate  the  draining  away  of  the 
exudation.  Often  in  the  early  morning 
the  bronchitic  brings  up  a  large  quantity 
of  sputum  by  the  help  of  more  or  less 
persistent  coughing.  At  this  time  the 
patient  should  lie  as  flat  as  possible  for 


a  couple  of  hours,  so  as  to  assist  the 
draining  of  the  secretion  into  the  large 
bronchi,  and  hence  its  expectoration. 
The  patient  can  expectorate  by  turning 
the  head  to  one  side.  After  a  few  days 
the  foot  of  the  bed  may  be  raised  8  or 
12  inches.  In  suitable  cases  in  two  to 
four  A\eeks  there  is  a  considerable  dimi- 
nution in  the  sputum.  This  mode  of 
treatment  is  adapted  to  cases  of  chronic 
bronchitis  which  have  led  to  a  cylindrical 
or  sacculated  bronchiectasis  in  the  lower 
lobes  of  the  lung.  It  is  of  no  avail  in 
cases  of  diffuse,  and  especially  recent, 
bronchitis,  with  general  secretion,  or  in 
cases  of  abscess-cavities  communicating 
laterally  or  incompletely  with  the  bron- 
chi, or  of  cavities  with  irritating  eon- 
tents.  Quincke  (Berl.  klin.  Woch.,  June 
13,  '98). 

The  diet  should  be  nourishing  and 
should  be  strictly  regulated  to  the  condi- 
tion of  the  digestive  organs.  Excess  of 
starches  is  to  be  avoided  because  of  their 
tendency  to  cause  flatulence  and  con- 
sequent mechanical  interference  with 
respiration.  In  cases  associated  with 
gout  the  question  of  diet  is  one  of  ex- 
treme importance. 

Foetid  Bronchitis. 

This  form  is  only  difEerentiated  from 
others  by  the  odor  of  the  sputum.  In 
many  cases  this  is  due  to  retention  of 
the  secretion  in  bronchieetatic  cavities. 
(See  Beonchiectasis.) 

Symptoms. — Fretid  bronchitis  begins 
as  an  ordinary  bronchitis,  which  later  as- 
sumes the  purulent  form;  or  it  may  be 
ingrafted  upon  a  chronic  pneumonia,  a 
bronchiectasis,  or  even  a  suppurative 
pleuritis  that  has  perforated  into  the 
lung.  The  early  symptoms  are  those 
of  simple  bronchitis.  The  pulse  is  rapid 
and  there  is  continuous  fever,  but  the 
temperature-record  is  usually  irregular. 
The  change  to  purulent  inflammation 
may  be  marked  by  a  chill  or  a  succession 
of  chills.  Eespiration  is  accelerated,  and 
the  severe  cough   causes  the   abundant 


650 


BRONCHITIS.    FCETID.    ETIOLOGY  AND  PATHOLOGY.    TREATMENT. 


expectoration  of  an  alkaline,  semi- 
liquid,  putrid  sputum,  which  sometimes 
amounts  to  seven  or  eight  hundred  cubic 
centimetres  per  day.  This  sputum  pos- 
sesses an  odor  said  to  be  quite  charac- 
teristic of  the  disease,  and  resembling 
somewhat  that  of  acacia-blossoms.  The 
disease  may  terminate  favorably,  or  it 
may  cause  death  by  the  development  of 
pneumonia,  bronchiectasis,  abscess,  or 
gangrene.  There  seems  to  be  no  specific 
sign  or  symptom  of  the  affection,  unless 
it  be  the  peculiar  odor  of  the  sputum, 
which  Lumniczer  claims  is  developed  by 
the  growth  of  the  bacilli  that  cause  the 
disease.     (Whittaker.) 

Death  is  generally  due  to  exhaustion 
or  through  some  intercurrent  disorder 
kindred  to  the  major  affection. 

Ulceration,  ampullar  dilatation  of  the 
bronchi,  pneumonia,  pleurisy,  gangrene, 
and  metastatic  purulent  deposits  in  other 
regions  are  the  main  complications  of 
this  stage  of  bronchitis.  Abscess  of  the 
brain  may  thus  become  the  cause  of 
death. 

Etiology  and  Pathology. — It  is  prob- 
able that  in  all  cases  retention  of  the 
secretion,  with  bacterial  activity,  is  the 
cause  of  the  foetor.  Leyden  and  Jaffe 
found  small  rod  forms,  to  which  they 
gave  the  name  "leptothris  pulmonalis." 
They  also  noticed  in  the  putrid  sputum 
numbers  of  spirilla  and  infusoria.  Lum- 
niczer describes  a  short,  somewhat 
curved  bacillus,  which  he  found  in  great 
numbers  in  the  plugs  of  pus  and  detritus 
expectorated,  which  give  the  sputum  its 
characteristic  foul  odor.  More  recently 
Hitzig  isolated  two  species  of  bacillus, 
the  one  presenting  the  characteristics  of 
the  coli  bacillus — short,  thick  rods — 
did  not  liquefy  in  gelatin;  was  found 
pathogenic  for  guinea-pigs  and  rabbits. 
The  second  did  not  liquefy  in  gelatin 
and  was  pathogenic  for  mice  and  guinea- 


pigs.  This  question  may  still  be  said  to 
be  sub  judice. 

Besides  the  causative  factors  acting 
in  the  case  of  chronic  bronchitis,  re- 
peated exposure  to  dust,  especially  that 
originating  from  dyed  woolens  or  cotton 
fabrics,  is  prone  to  lead  to  the  foetid 
form:  a  mere  complication  of  those 
already  described. 

Treatment. — The  agents  recommended 
in  chronic  bronchitis  are  also  valuable 
here,  especially  the  balsams,  terpine,  tur- 
pentine, or  terebene.  Five  to  10  min- 
ims of  the  latter  in  capsules,  taken 
after  meals,  are  very  effective  in  most 
cases.  The  preparations  of  tar,  already 
mentioned,  are  also  valuable.  In  cases 
in  which  the  foetid  expectoration  only 
occurs  at  intervals,  sandal  yields  gratify- 
ing results.  Narcotics  should  be  avoided. 
Hyposulphite  of  soda  has  been  highly 
extolled;  it  promptly  changes  the  char- 
acter of  the  expectorated  material  and 
thus  eliminates  the  fcetor. 

Naphthalin  is  an  excellent  remedy  in 
foetid  bronchitis.  Following  mixture  may 
be  given: — • 

IJ  Naphthalin,  1  drachm. 
Absolute  alcohol, 
Syr.   of  wild   cherry,  of  each,   1  Vz 

fluidounces. 
Fl.  ext.  of  squill,  4  fluidrachms. 
Tinct.  of  aconite,  8  drops. 
Teaspoonful  every  three  hours. 
The   following   capsules   may   be   also 
taken  with  the  above:  — 
R  Iodoform, 

Calcium     phosphate,    of    each,    24 

grains. 
Powd.  ipecac, 
Ext.    of    hyoscyamus,    of    each,    6 

grains. 
Powd.  opium,  4  grains. 
Oil  of  anise,  10  drops. 
Divide  into  twenty-four  capsules.    One 
every    three   hours.      Pirnot    (St.    Louis 
Med.  Era,  Sept.,  1900). 

Intratracheal  injections  have  been  rec- 


BRONCHITIS.     FIBRINOUS.     SYMPTOilS.     ETIOLOGY. 


651 


ommended,  the  agents  used — menthol, 
camphor,  etc. — being  dissolved  in  oil  or 
albolene.  A  Pravaz  syringe  with  a  long 
curved  tip,  which  may  readily  be  in- 
troduced into  the  larynx,  is  used.  Fif- 
teen to  30  minims  are  well  borne,  and 
if  properly  applied  excite  comparatively 
no  cough.  Nitrate-of-silver  solutions  of 
varying  strengths  have  also  been  em- 
ployed, but  one  exceeding  10  grains  to 
the  ounce  is  apt  to  excite  laryngeal 
spasm.  Still,  much  stronger  solutions 
have  been  employed  with  impunity. 

Fibrinous,  or  Plastic,  Bronchitis. 

In  this  variety  the  secretion  from  the 
mucous  membrane  tends  to  form  co- 
herent easts  of  the  bronchial  tree. 

Symptoms.  —  Fibrinous,  or  plastic, 
bronchitis  is  characterized  by  the  occur- 
rence of  paroxysms  of  cough  and  dysp- 
noea, which  immediately  cease  on  the 
expectoration  of  the  casts.  The  par- 
oxysms are  usually  preceded  and  fol- 
lowed by  a  sort  of  catarrh.  Hasmop- 
tysis  may  be  absent  or  it  may  be  very 
'serious.  It  usually  ceases  at  once  with 
the  ejection  of  the  casts.  As  a  general 
thing,  but  little  pain  is  present,  except 
that  caused  by  coughing.  In  acute  cases 
the  temperature  may  rise  to  104°  F.; 
in  chronic  cases  it  is  seldom  above  nor- 
mal. Sometimes  the  onset  of  an  attack 
is  marked  by  one  or  more  rigors:  sug- 
gestive of  pneumonia.  As  a  rule,  each 
attack  consists  of  a  number  of  short  par- 
oxysms. It  may  subside  after  a  few 
days  never  to  recur  again,  or  may  last 
continuously  for  ten,  fifteen,  or  twenty 
years.     (West.) 

Auscultation  and  percussion  reveal 
signs  similar  to  those  witnessed  in 
chronic  catarrhal  bronchitis,  but  they 
occupy  a  limited  area  like  those  of  ob- 
structed bronchioles;  from  time  to  time, 
intense  paroxysmal  cough  occurs,  accom- 
panied with  dyspnoea  and  cyanosis,  end- 


ing in  the  expectoration  of  the  pathog- 
nomonic sputa. 

Etiology.  —  Although  syphilis  and 
tuberculosis  have  been  considered  as 
etiological  factors,  it  is  probable  that 
these  diathetic  afEections  were  probably, 
in  the  cases  reported,  but  concomitant 
disorders — manifestations  originating  in 
local  and  general  depravity.  Indeed, 
in  many  cases  no  diathesis,  inherited  or 
acquired,  could  be  discerned.  There 
seems,  however,  to  be  a  familial  tend- 
ency to  the  affection,  several  members 
of  individual  family  having  sufEered 
from  it  as  a  result  of  bronchial  catarrh. 
This  sufficiently  indicates  how  obscure 
is  our  knowledge  of  the  causes  of  this 
affection.  Plastic  bronchitis  occurs  fre- 
quently after  pneumonia.  In  some  cases 
it  is  associated  with  grave  skin  affections. 
There  seemed  in  one  case,  also,  to  be  a 
relation  between  the  formation-casts  and 
the  catamenia.    (West.) 

Analysis  of  all  the  cases  recorded  in 
the  literature  show  that  they  can  he 
grouped  in  nine  classes  as  follows:  I. 
Chronic  bronchitis  with  expectoration 
of  branching  easts  of  the  bronchial  tree. 

2.  Acute  bronchitis  with  expectoration 
of  branching  casts  of  the  bronchial  tree. 

3.  Cases  in  which  branching  casts  were 
not  expectorated,  but  were  found  in 
the  bronchi  at  autopsy.  4.  Casts  ex- 
pectorated, but  not  showing  branching. 
5.  Branching  easts  expectorated  asso- 
ciated with  organic  heart  disease.  6. 
Branching  casts  expectorated  in  pul- 
monary tuberculosis.  7.  Small  casts, 
often  non-branching,  associated  with 
asthma.  8.  Casts  m  the  bronchi  asso- 
ciated with  pulmonary  cederaa  following 
thoracentesis.  Cases  incompletely  re- 
ported. 

The  most  important  form  is  the  first, 
and  the  results  show  that  it  occurs  in 
either  sex,  increases  to  middle  age,  and 
then  declines,  and  in  several  cases  the 
patients  were  exposed  to  dusty  atmos- 
pheres. Occasionally  some  infectious 
disease    precedes    the    attack,    or    there 


652 


BRONCHITIS.     FIBRINOUS.     PATHOLOGY. 


may  be  some  chemical  irritant,  or  a 
family  history  of  tuberculosis.  Nearly 
all  the  patients  had  suffered  from 
chronic  bronchitis  for  some  time.  The 
symptoms  consist  of  an  exacerbation  of 
chronic  catarrh.  The  disease  is  par- 
oxysmal and  may  last  for  many  years. 
The  symptoms  are  dyspnoea,  cough,  oc- 
casionally slight  fever,  and  very  occa- 
sionally haemoptysis.  The  physical  signs 
are  not  characteristic,  there  may  be  all 
types  of  rales,  and  the  patient  may 
emaciate  considerably.  The  subjective 
symptoms  are  usually  oppression  and 
tightness  until  the  cast  is  expectorated. 
A  curious  feature  is  that  in  many  eases 
there  has  been  an  associated  affection 
of  the  skin.  Of  those  casts  examined 
the  majority  were  composed  of  mucin. 
The  bronchial  mucous  membrane  usually 
does  not  show  any  characteristic  change. 
In  the  acute  form  the  symptoms  are 
somewhat  similar,  but  there  is  usually 
a  history  of  an  acute  infectious  disease. 
Bettman  (Amer.  Jour.  Med.  Sciences, 
Feb.,  1902). 

Pathology. — The  casts  may  be  found 
rolled  up  in  the  form  of  balls  in  the 
sputum.  On  mixing  the  sputum  with 
water  the  casts  are  unrolled  and  may 
be  spread  out  with  needles.  In  some 
cases  they  are  associated  with  Cursch- 
mann's  spirals  and  Charcot-Leyden 
crystals.  Bronchial  casts  are  occasion- 
ally seen  in  croupous  pneumonia,  in 
diphtheria,  and  in  htemoptysis,  but 
these  casts  are  to  be  explained  other- 
wise than  as  examples  of  fibrinous  bron- 
chitis. Eppinger  has  observed  that  in 
croupous  exudation  there  seems  to  be  a 
central  condensed  mass  of  exudate, 
which  serves  as  a  nucleus  upon  which 
are  deposited  successive  layers  of  trans- 
lucent fibrin.  The  mucous  membrane 
is  not  infiltrated,  as  it  is  in  a  croupous 
exudation.  Eppinger  advanced  the  idea 
that  on  account  of  a  chronic  congestive 
catarrh  of  the  bronchi  the  permeability 
of  the  walls  of  the  vessels  of  the  sub- 
mucous  connective   tissue   is   increased 


and  allows  the  fibrinogenous  substance 
of  the  blood  to  escape.  This  transuda- 
tion, moreover,  is  favored  by  the  attenu- 
ated epithelial  covering  of  the  tubes:  a 
condition  that  is  the  direct  result  of  the 
catarrhal  inflammation  present  in  nearly 
all  these  cases.  The  exact  cause  of  this 
cast-formation  has  not  been  definitely 
determined.  That  the  casts  are  com- 
posed of  mucus,  and  not  of  fibrin,  has 
been  definitely  proved  by  Graudy.  In 
a  case  in  which  the  casts  were  expelled 
in  great  numbers  Stirling  foitnd  that  the 
majority  measured  from  3  to  4  inches, 
some  as  much  as  6  inches.  They  had 
evidently  been  deposited  in  sitccessive 
layers  and  in  concentric  laminse,  which 
could  be  separated  when  dry.  They 
consisted  of  coagulated  albumin  soluble 
in  alkalies.  They  showed  fibrillary  mate- 
rial, in  the  meshes  of  which  were  numer- 
ous leucocytes  and  fat-globules,  some 
haemocj'tes,  and  epithelial  cells.  Octa- 
hedral crystals,  said  to  be  similar  to  those 
found  in  bronehitic  asthma,  have  been 
observed  by  others,  but  the  spirals  seen 
by  Curschmann  were  not  found  by  Stir- 
ling. 

Case  in  which  the  autopsy  showed 
that  the  pseudomembranes  extended 
from  the  posterior  nasal  outlets  clear 
down  to  the  third  divisions  of  the 
bronchi.  The  only  bacteriological  ele- 
ment found  was  the  staphylococcus. 
3.  Glover  (Anna,  des  Mai.  de  I'Oreille, 
du  Larynx,  etc..  No.  5,  '96). 

Case  in  which  the  patient  had  suffered 
from  the  disease  for  some  years,  and 
was  constantly  expectorating  bronchial 
casts.  All  the  cover-slips  from  the  casts 
showed  streptococci;  the  inner  surface 
showed  micro-organisms  of  varying 
kinds,  probably  coming  from  the  saliva. 
The  disease  due  to  the  streptococcus; 
^larmorek's  antistreptococcic  serum 
used.  After  two  months'  treatment  the 
patient  was  discharged  much  improved. 
The  reaction  to  the  antistreptococcic 
serum  a  further  proof  of  the  nature  of 


BRONCHITIS.     FIBRINOUS.     TREATMENT. 


653 


the  disease.  Claisse  (Comptes-Rendus 
de  la  Soc.  de  Biol.,  Apr.  3,  '96). 

Histological  appearances  in  the  bron- 
chi of  a  patient  snflfering  from  this  dis- 
ease who  died  of  cardiac  failure.  Neel- 
sen  had  found  them  to  consist  of 
mucus:  a  view  which  had  hitherto  met 
with  no  support.  In  this  case  the  easts 
were  found  to  consist  apparently  of 
fibres  inclosing  masses  of  leucocytes  and 
large,  swelled,  round  epithelial  cells. 
Weigert's  fibrin  stain  gave  no  colora- 
tion, thionin  a  faint  pink;  Curschmann's 
spirals  were  absent,  this  being  the  sole 
point  of  difference  from  Neelsen's  re- 
sults. The  casts  were  thus  composed 
of  mucus,  and  not  of  fibrin.  With  re- 
gard to  the  bronchi,  the  epithelium  was 
intact  except  in  a  few  spots;  Weigert 
pointed  out  many  years  ago  that  fibri- 
nous exudates  only  arose  where  the 
epithelium  had  been  shed  over  large 
areas.  In  the  case  under  notice  the 
goblet-ceUs  were  unusually  numerous, 
and  the  glands  had  undergone  mucoid 
degeneration,  their  ducts  being  filled 
with  mucus.  The  origin  of  the  casts 
was  thus  obvious.  Graudy  (Centralb. 
f.  allgem.  Path.,  vol.  viii,  No.  13,  '97). 

Examination  of  two  cases  secondary 
to  valvular  disease.  Stained  by  Wei- 
gert's method,  they  showed  very  fine 
fibrin-fibres,  most  of  the  casts  not  tak- 
ing any  stain  (lithium  carmine.)  Chem- 
ical examination  also  showed  the  ab- 
sence of  fibrin,  but  proved  that  the 
easts  were  made  up  chiefly  of  mucin. 
The  casts  were  of  acid  reaction,  and  the 
writer  thinks  this  is  the  cause  of  the 
coagulation.  According  to  his  view 
something,  probably  the  action  of  bac- 
teria, causes  the  bronchial  secretions 
to  become  acid.  The  mucus  then  coag- 
ulates. The  same  explanation  appeared 
to  the  casts  sometimes  expectorated  in 
croupous  pneumonia,  and  was  able  to 
confirm  his  view  in  a  case  of  the  latter 
disease.  A.  Habel  (Centralb.  f.  inn. 
Med.,  No.  1,  '98). 

Case  in  which  microscopical  examina- 
tion of  the  lungs  showed  a  rather  exten- 
sive tuberculosis  of  the  pulmonary  tissue, 
but  no  tuberculosis  of  the  bronchi.  In 
fact,  the  mucous  membrane  of  the  bron- 


chial tubes  was  practically  normal.  In 
the  pulmonary  tissue  a  considerable 
quantity  of  fibrin  was  also  present.  Bac- 
teriologieally,  only  streptococci  were 
found.  Apparently  there  is  desquama- 
tion from  the  alveoli  of  the  lung,  and 
masses  of  fat  and  epithelial  cells  are 
sometimes  found  in  the  easts.  These  con- 
ditions occur  acutely  and  by  a  process 
analogous  to  that  in  eases  of  asthma: 
that  is  to  say,  as  a  result  of  desquama- 
tion itself,  an  exudation  due  to  nervous 
influence,  and  a  subsequent  coagulation. 
The  nature  of  the  irritation  is  very 
various.  Schittenhelm  (Deut.  Archiv  f. 
klin.  Med.,  B.  67,  H.  3  and  4,  1900). 

Treatment. — The  treatment  does  not 
differ  from  that  of  other  forms  of  bron- 
chitis except  the  fact  that  alkalies  (po- 
tassium iodide  and  carbonate)  and  alka- 
line steam-sprays  are  of  more  decided 
value.  The  iodide  of  potassium  acts  by 
stimulating  secretion  and  thus  assisting 
in  the  elimination  of  the  pseudomem- 
brane.  It  must,  however,  be  given  in 
large  doses. 

Inhalations  of  alkalies  recommended. 
Especially  valuable  are  aqua  calcis, 
alone  or  with  equal  parts  of  water,  or 
with  2  to  5  per  cent,  of  carbonate  or 
bicarbonate  of  sodium,  in  which  the 
casts  are  soluble.  Stirling  (London 
Pract.,  June,  '89). 

Case  in  which  45  grains  in  divided 
dose  was  administered  daily  to  induce 
mucoid  exudation  in  the  bronchi  and 
facilitate  the  ejection  of  the  casts, 
which,  in  the  present  case,  were  found 
to  consist  mainly  of  mucin  containing 
staphylococci  and  a  special  bacillus. 
The  patient  was  permanently  cured. 
Huchard    (Semaine  Med.,  July  28,  '95). 

Potassium  iodide  is  probably  the  most 
useful  remedy  in  all  forms  of  the  dis- 
ease, as  it  increases  the  bronchial  secre- 
tion when  given  during  the  acute  parox- 
ysm, and  thus  aids  in  expelling  the 
casts.  It  also  seems  to  lessen  the 
tendency  to  recurrence  of  attacks  if 
given  in  full  doses  and  for  a  long  period 


654 


BUCKTHORN. 


BURNS. 


of  time.     J.  W.  Brannan    (Med.  News, 
Aug.   15,  '96). 

Feedeeick  a.  Packaed, 

Philadelphia. 

BRONCHOCELE.    See  Goitee. 

BEONCHO-PNEUMONIA.  See  Pneu- 
monia. 

BRONCHORRHCEA.   See  Beonchitis. 

BUBO.  See  Syphilis  and  Ueinaey 
System. 

BUBONIC  PLAGUE.     See  Plague. 

BUCKTHORN     (CASCARA).— The 

bark  of  the  European  buckthorn  (Eliam- 
nus  frangula)  and  that  of  the  Californian 
variety  {R.  pu'rshiana),  in  spite  of  the 
interested  claims  of  manufacturers,  are 
practically  identical  in  medicinal  effect; 
if  there  is  any  superiority,  it  lies  with 
R.  frangula.  Both  require  that  the  bark 
should  be  carefully  gathered,  dried,  and 
allowed  to  lie  for  at  least  two  years  in 
order  to  get  rid  of  a  principle  therein 
that  is  likely  to  induce  griping. 

The  active  (neutral)  principle — "cas- 
cara  sagrada,"  the  source  of  the  Cali- 
fornian bark — is  supposed  to  be  a  gluco- 
side,  termed  "cascarin,"  but  this  bap- 
tism is  entirely  superfluous,  since  it  is 
identical  with  the  principle  found  in  the 
European  bark,  known  as  frangulin  and 
xanthin. 

Physiological  Action.  — -Buckthorn 
and  cascara  are  laxative,  slightly  tonic, 
and  stomachic.  If  both  are  prepared 
and  administered  in  the  same  way,  the 
results  will  be  found  to  be  identical. 

Preparations  and  Doses.  —  Abstract 
buckthorn  (or  cascara),  3  to  15  grains. 

Extract  buckthorn  (or  cascara),  1  to 
8  grains. 

Extract  buckthorn  (or  cascara),  taste- 
less, 1  to  8  grains. 


Fluid  extract  buckthorn  (or  cascara), 
3  to  45  minims. 

Fluid  extract  buckthorn  (or  cascara), 
aromatic,  3  to  45  minims. 

Cascara  cordial,  1  to  4  drachms. 

Elixir  buckthorn,  ^/^  to  2  drachms. 

Cascarin  (or  frangulin),  concentration, 
1  to  8  grains. 

Therapeutics. — These  preparations,  to 
secure  their  best  laxative  effects,  should 
be  given  half  an  hour  after  meals,  and 
increased  or  diminished  in  dose,  or  re- 
peated at  lesser  intervals,  according  to 
the  action  desired.  In  habitual  consti- 
pation the  best  results  are  obtained  by 
giving  small  doses  at  frequent  intervals, 
thereby  securing  a  continuous  impres- 
sion on  the  digestive  tract. 

BUNION.    See  Tendons,  Buesitis. 

BURNS. 

Definition.- — A  burn  is  a  high  grade 
of  acute  inflammation,  following  the 
direct  or  indirect  application  of  dry  or 
moist  heat  to  a  portion  of  the  cutaneous 
or  mucous  surfaces. 

Varieties.  —  For  ease  of  comprehen- 
sion burns  have  been  separated  into 
grades  according  to  their  severity.  The 
character  of  inflammation  observed  in 
these  grades  is  governed  by  the  exciting 
agent,  its  capacity  for  the  absorption  of 
heat,  the  duration  of  its  contact,  and  the 
susceptibility  of  the  part  acted  upon. 
Solid  substances  (copper  and  iron)  and 
the  fixed  oils  (olive  and  linseed)  cause 
a  greater  impression  than  volatile  (alco- 
hol, ether,  and  chloroform)  or  aqueous 
(water  and  vapors)  materials.  Certain 
articles,  owing  to  their  tenacity  (copper), 
although  absorbing  the  same  amount  of 
heat  as  others  (iron),  cause  more  decided 
destruction. 

The  length  of  contact,  giving  in  the 
shorter  periods  a  superficial  incineration 


BURNS.    SYMPTOMS. 


655 


and  in  the  longer  a  deeper  destruction,  is 
of  importance  in  determining  the  grade 
of  inflammation.  The  more  dense  and 
thick  portions  of  the  skin  (buttocks, 
palms,  and  soles)  offer  greater  resist- 
ance than  those  of  thinner  (face,  neck, 
and  abdomen)  texture. 

The  effect  upon  the  system  will  de- 
pend upon  the  character  of  person  at- 
tacked, those  of  stronger  constitutions 
being  the  more  able  to  controvert  shock 
than  those  of  weaker  frame. 

A  temperature,  slightly  increased 
above  the  normal  (as,  for  instance,  100° 
F.),  produces  only  a  slight  hypersemia 
(first  degree:  dermatitis  ambustionis 
erythematosa),  which  may  disappear 
shortly  after  breaking  the  contact,  while 
a  rise  to  150°  F.  will  cause  some  appear- 
ance of  vesicles  and  bulla  (second  de- 
gree: dermatitis  ambustionis  vesiculosa 
et  bullosa)  and  destruction  of  the  epi- 
dermis, the  efEect  of  which  is  not  re- 
lieved for  days  after  the  removal  of  the 
burning  substance,  and  yet,  on  the  other 
hand,  heat  at  the  boiling-point  of  water 
(313°  F.)  may  cause  a  complete  carbon- 
ization of  the  part,  resulting  in  the 
formation  of  eschars  varying  in  color 
from  a  yellow  up  to  a  dark  brown  or 
black  or,  in  other  words,  the  production 
of  gangrene  (third  degree:  dermatitis 
ambustionis  escharotica  sen  gangrenosa). 

Symptoms.  —  The  effects  of  a  burn 
upon  the  body-structure  are  both  local 
and  constitutional.  The  former  often 
results  in  great  disfiguration  or  destruc- 
tion of  tissue,  while  the  latter  depresses 
the  vital  forces  or  terminates  in  death. 

Local  Effects.  —  In  burns  of  the 
■first  degree  the  appearances  produced  are 
superficial.  There  will  be  observed  a  dis- 
tinct hyperaemia  with  redness  of  varying 
intensity  from  the  slightest  blush  up  to 
a  pinkish  red  or  brownish  red.  This 
may  or  may  not  be  entirely  effaced  by 


pressure.  Persons  of  fair  complexion  or 
thin,  delicate  skin  are  affected  more 
greatly  by  the  same  amount  of  heat  than 
will  be  those  of  darker  hue  or  more  dense 
integument.  Swelling  is  present  to  a 
slight  degree  and  does  not  extend  far 
beyond  the  limits  actually  exposed  to 
the  burning  substance.  This  type  of 
bum  is  produced  by  indirect  contact 
with  the  flame  of  a  lighted  match,  prox- 
imity to  a  heated  metal,  escaping  steam, 
and  the  actinic  rays  of  the  sun. 

With  or  without  treatment  the  effect 
of  burning  to  this  extent  may  disappear 
shortly  after  removing  the  exciting 
cause.  Eesolution  takes  place  in  this 
variety  by  the  disappearance  of  the 
swelling,  the  serous  infiltration  being 
absorbed,  the  color  diminishing  to  the 
normal  except  in  those  cases  in  which  a 
slight  degree  of  pigmentation  is  left  in 
the  form  of  ordinary  increase,  which 
usually  disappears  as  time  progresses  or 
where  the  sun's  raj^s  cause  perhaps  a  per- 
manent stain  such  as  lentiginous  patches. 
The  linear  fissures  of  the  skin  appear 
prominent  because  of  the  semidetach- 
ment  of  the  membrane  between  them, 
which,  as  time  passes,  the  new  skin  form- 
ing beneath  compels  their  complete  de- 
tachment in  the  form  of  minute  flakes 
of  deadened  epithelium. 

In  burns  of  the  second  degree  the  in- 
flammation, while  yet  superficial,  may 
still  occupy  the  entire  epidermis.  In 
some  cases  the  upper  layers  alone  of  the 
cuticle  may  be  destroyed,  while  vesicles 
or  bulla  may  be  observed  over  the  af- 
fected surface.  In  still  other  cases  the 
corium  is  stripped  entirely  of  its  epi- 
dermal covering  or  particles  of  the  mem- 
brane may  be  rolled  into  whitish  masses 
over  its  exposed  surface.  These  vesicles 
or  bulla  may  be  produced  directly  by  the 
contact  of  the  heated  article  or  indirectly 
by  the  consequent  inflammation.     They 


656 


BURNS.     SYMPTOMS. 


may  retain  their  contents  or,  owing  to 
the  increased  flow  of  serum,  their  walls, 
becoming  thin  and  losing  their  elasticity, 
rupture,  thus  allowing  the  escape  of  a 
continual  discharge  over  the  denuded 
surface.  The  true  skin,  which  is  ex- 
posed either  entirely  or  at  points,  shows 
a  highly-reddened  surface,  over  which 
this  continual  exudation  may  be  ob- 
served. The  papillary  vessels  are  seen 
to  be  deeply  congested,  or,  if  ruptured, 
their  flow  of  blood  intermingles  with  the 
discharge  of  serum  and  gives  it  a  tint  of 
red.  Swelling  is  present  in  both  of 
these  conditions,  but  is  governed  by  the 
extent  of  surface  and  the  density  of  the 
part  involved.  In  this  type  of  condition 
actual  contact  with  the  heated  substance 
takes  place  either  in  shorter  or  longer 
durations.  Such  articles  as  heated  iron, 
transient  or  lengthened  action  of  flames, 
and  boiling  liquids  may  be  the  exciting 
agent.  The  effects  of  this  form  of  burn 
do  not  always  shew  to  what  extent  they 
have  progressed  immediately  upon  the 
removal  of  the  cause,  because  of  the  sys- 
temic conditions  which  may  be  induced. 
Pain  is  always  present  to  a  minor  or  ma- 
jor degree. 

Eesolution  takes  place  through  co- 
agulation of  the  serous  discharge,  which 
occupies  the  involved  area  as  a  fibro- 
albuminous  covering,  beneath  which  the 
new  skin  is  allowed  to  form.  After  the 
new  integument  has  progressed  almost 
to  its  normal  aspect  this  covering,  which 
by  this  time  has  become  a  darkish  crust, 
becomes  loosened  and  falls  off,  exposing 
a  thin,  delicate  skin,  through  which  the 
more  vascular  structures  immediately 
beneath  are  observed.  It  is  not  for 
weeks,  months,  or  even  years  that  the 
normal  pinkish-red  tint  of  the  skin  is 
restored.  Burns  of  this  character  usu- 
ally leave  a  fairly-normal  aspect  to  the 
surface  and  rarelv  cause  the  formation 


of  cicatrices.  If  a  cicatrix  is  formed, 
it  is  generally  superficial  and  flattened, 
resembling,  to  a  marked  degree,  the  flat, 
sebaceous  warts  observed  in  the  aged. 

In  the  burns  of  the  third  degree  the 
inflammation  or  destruction  may  be  su- 
perficial, extending  over  considerable 
area,  or  deep,  affecting  the  subcutaneous 
tissues,  muscles,  and  even  bones.  In 
those  of  the  superficial  variety  the  ex- 
tent of  surface-involvement  may  be  vari- 
able, in  one  instance  occupying  a  por- 
tion comparing  with  the  size  of  the  hand, 
and  in  others  being  observed  upon  por- 
tions ranging  from  six  or  seven  inches 
to  areas  as  large  as  one  limb  or  even 
one-third  or  one-half  of  the  surface  of 
the  body.  In  this  variety  the  epidermis 
alone  may  be  destroyed  and  expose  the 
corium  to  view,  covered  with  particles  of 
charred  cuticle,  or  the  corium  itself  may 
share  in  the  destruction,  being  deposited 
over  the  affected  areas  in  strips  of  dried 
eschars.  The  parts  uncovered  by  these 
destructive  influences  present,  either  the 
corium  or  subcutaneous  tissue,  a  highly- 
vascular  aspect,  from  which  there  is  a 
continuous  exudation  of  serum  inter- 
mingled with  the  escaping  blood.  The 
dead  tissues  vary  in  proportion  according 
to  extent  of  heat,  its  length  of  contact, 
the  thinness  or  density  of  the  part  in- 
volved, and  the  amount  of  surface  en- 
compassed. They  may  be  thin  or  thick, 
large  or  small,  and  retain  their  hold  for 
longer  or  shorter  periods. 

Eesolution  takes  place  in  the  uncov- 
ered variety  in  the  same  manner  as  de- 
scribed under  the  foregoing  degree, 
while  in  the  covered  variety  granula- 
tions spring  up  beneath  the  charred  re- 
mains which,  after  a  time,  desiccate  and 
fall  off,  exposing  a  similar  surface  to 
that  of  the  second  degree. 

In  the  deeper  form  of  burn  the  extent 
of   surface   involved    may   be    small    or 


BURNS.    SYMPTOMS. 


657 


large,  but  may  dip  down  to  varying 
depths.  It  may  be  limited  to  the  de- 
struction of  the  skin  (epidermis  and 
corium)  and  the  subcutaneous  tissues,  or 
it  may  expose  the  muscles,  attack  the 
nerves  and  blood-vessels  (allowing  hem- 
orrhage), and  even  the'  bone.  The 
amount  of  charring  will  usually  be  very 
great  and  will  lay  about  in  masses  over 
the  burned  surface,  thus  preventing  a 
view  of  the  destruction  beneath.  In 
some  cases  the  degree  of  loss  will  be  so 
enormous  that  the  bone  will  be  entirely 
stripped  of  all  covering.  Hemorrhages 
will  often  be  encountered  and  may  re- 
sult fatally.  Fractures  of  bone  will  oc- 
casionally complicate  matters.  This 
variety  will  show  both  the  first  and  sec- 
ond degrees  at  areas  remote  from  the 
greatest  destruction.  Resolution  even 
in  the  milder  cases  is  slow,  and  before 
such  happens  surgical  interference  may 
be  demanded.  The  same  appearances 
may  be  noted  throughout  its  process  as 
found  in  the  superficial  variety,  but  to  a 
different  degree.  The  causes  which 
bring  about  this  form  of  burning  are 
usually  dry  heat  (flames  or  contact  with 
electric  wires),  and  it  generally  causes 
much  greater  destruction  than  will  moist 
heat.  The  effect  upon  the  system  is 
generally  of  an  alarming  character,  and 
shock  may  carry  off  the  person  before 
relief  can  even  be  attempted. 

Electric  and  X-ray  Burns.  —  Burns 
from  electricity  may  be  observed  in  all 
the  varieties  mentioned  above.  They 
may  follow  direct  or  indirect  contact. 
Examples  of  direct  contact  are  observed 
after  handling  live  (charged)  wires,  and 
may  be  found  to  destroy  all  parts  with 
which  it  comes  into  touch,  or  life  even 
may  be  the  forfeit. 

Case  of  severe  electrical  bum  in  an 
electrician  employed  in  the  electric  plant 
used  to  furnish  power  to  the  city  street- 

1- 


car  line  and  to  the  arc  and  incandescent 
lights  of  the  city.  The  patient  had  acci- 
dentally brought  his  back  in  contact 
with  the  positive  and  negative  keys  of 
the  switchboard  of  arc-line  furnishing 
96  street-lamps  and  carrying  4000  volts 
of  electricity.  He  was  released  by  the 
tissues'  being  burned  away  in  two  pits 
about  three  inches  in  diameter  and  down 
to  the  bony  structures.  The  intervening 
space  between  these  pits,  which  were  ten 
inches  apart,  was  roasted,  and  after  the 
lapse  of  a  few  weeks  was  lifted  out.  It 
weighed  two  pounds  and  a  half.  The 
sloughing  was  such  that  the  cotton, 
bandages,  clothing,  and  bed  were  sat- 
urated with  pus.  Recovery.  J.  F. 
Weathers  (N.  Y.  Med.  Jour.,  Apr.  2,  '98). 

The  following  peculiarities  attributed 
to  electrical  burns:  At  first  they  look 
dry,  crisp,  and  bloodless,  and  are  exca- 
vated. But  serious  oozing  and  hyper- 
Eemia  occur  within  thirty-six  hours,  pain 
is  moderate,  and  the  systemic  shock  con- 
siderable. N.  W.  Sharp  (Phila.  Med. 
Jour.,  Jan.  29,  '98). 

A  most  recent  form  of  burning  of  the 
skin  from  the  indirect  contact  of  elec- 
tricity is  by  the  x-ray  apparatus.  Close 
proximity  to  the  ray  by  either  covered  or 
uncovered  parts  result  either  in  a  super- 
ficial or  deep  inflammation  of  the  skin. 
It  may  be  observed  a  few  hoitrs  after  ex- 
posure to  the  rays  or  may  be  delayed  for 
several  weeks.  Gilchrist,  of  Baltimore, 
in  a  case  did  not  see  any  eiSect  for  sev- 
eral (three)  weeks  after  exposure,  while 
Crocker,  of  London,  observed  a  case  in 
which  the  effects  were  produced  in  one 
day  thereafter.  This  form  of  burning 
attacks  the  skin  alone  in  some  instances, 
while  in  others  the  deeper  structures,  as 
the  muscles,  tendons,  nerves,  and  bones 
(periostitis  and  ostitis  resulting)  are  in- 
volved. The  effects  may  remain  for 
days,  weeks,  or  even  months  after  the 
application.  X-ray  burns  are  supposed 
by  some  to  be  produced  by  the  action  of 
the  ray  or  by  particles  of  aluminium  or 


658 


BURNS.     COMPLICATIONS. 


platinum  reaching  and  being  deposited 

in  the  tissues  by  others. 

The  x-ray  per  se  is  incapable  of  injur- 
ing tlie  tissues  of  the  patient,  and  the 
dermatitis,  which  has  been  called  an  x- 
ray  "burn,"  is  the  result  of  an  interfer- 
ence with  the  nutrition  of  the  part  by 
the  induced  static  charges. 

The  patient  may  be  absolutely  pro- 
tected from  the  harmful  effects  of  tliis 
static  charge  by  the  interposition  between 
the  tube  and  the  patient  of  a  grounded 
sheet  of  conducting  material  that  is 
readily  penetrable  by  the  x-ray,  a  thin 
sheet  of  aluminium  or  gold-leaf  spread 
upon  card-board  making  an  effectual 
shield.  C.  L.  Leonard  (N.  Y.  Med.  Jour., 
July  2,  '98). 

Burns  of  Mucous  Surfaces. — The  mu- 
cous surfaces  may  be  affected  by  the  in- 
halation of  flames,  vapors  (volatile  or 
boiling  acids),  boiling  liquids  (water, 
slacked  lime),  and  by  certain  substances 
acting  directly,  such  as  ammonia  and 
sulphuric  and  hydrochloric  acids.  The 
mouth,  pharynx,  larynx,  bronchi,  and 
the  oesophagus,  as  well  as  the  stomach, 
share  in  the  attack.  The  eye  often, 
from  its  exposed  position,  is  the  seat  of 
burn.  Conjunctivitis  often  results  from 
irritants  coming  into  direct  contact  with 
the  eye,  and  if  the  exciting  agent  is  not 
soon  removed  great  destruction  of  sub- 
stance or  sight  may  be  the  result. 

Constitutional  Effects. — The  ef- 
fects of  burns  of  the  first  degree  upon 
the  system  are  generally  slight  and  are 
limited  to  pain,  which  disappears  shortly 
after  the  removal  of  the  exciting  agent, 
but  often  may  last  for  several  hours. 

In  burns  of  the  second  degree  the  pain 
accompanies  the  phenomena  not  alone 
for  hours  and  days,  but  often  for  weeks 
and  even  months.  The  shock  may  be  of 
a  transient  character  or  of  an  alarming 
intensity.  It  may  be  encountered  at  the 
time  of  accident  or  be  delayed  for  peri- 
ods varying  from  hours  to  days  there- 


after. When  small  areas  are  involved, 
the  depression  may  soon  be  relieved,  but 
when  one-fourth  or  one-third  of  the 
body  is  attacked  death  may  intervene. 

Burns  of  the  third  degree  may  be  so 
severe  that  death  intervenes  before  pain 
has  time  to  appear.  Shock  at  this  stage 
is  therefore  observed  early  and  of  the 
worst  character.  Early  mortality  is  gen- 
erally due  to  the  shock,  while  late  mor- 
tality usually  occurs  during  the  stage  of 
suppuration.  Vomiting  is  often  ob- 
served in  both  the  second  and  third  de- 
grees. 

Children  suffer  more  from  burns  than 
do  adults,  and  women  more  severely 
than  men.  The  temperature  is  not  af- 
fected by  burns  of  the  first  degree,  but 
is  a  marked  symptom  in  those  of  the 
second  and  third.  At  the  time  of  acci- 
dent it  may  decrease  from  one  to  three 
degrees  below  the  normal  (to  97°  or 
even  95°)  and  remain  at  that  point  until 
reaction  begins,  which  is  in  about  36  or 
48  hours,  when  it  rises  during  the  nest 
12  to  18  hours  to  104°  or  106°  or  more, 
at  which  point  it  remains  for  a  period 
of  8  to  10  daj's  (possibly  rising  and  low- 
ering at  irregular  intervals),  when  gran- 
ulations, now  in  a  fair  formation,  act 
as  a  retarding  agent. 

Complications. — The  after-effects  of 
burns  may  be  concentrated  upon  the  vis- 
cera (neural,  thoracic,  and  ventral  cavi- 
ties) or  directly  upon  the  part  affected 
(cicatrices,  contractions,  and  fractures  of 
bone).  Burns  of  the  first  degree  remain 
uncomplicated,  while  those  of  the  second 
and  third  present  many  variations.  The 
meninges  (arachnitis  following  burns  of 
the  head),  as  well  as  the  brain  proper, 
may  become  congested  or  even  highly 
inflamed,  the  sufferer  presenting  all  the 
symptoms  of  restlessness  and  delirium, 
ending  either  in  convulsions  or  coma. 
Tetanus   is   an   early   complication   ob- 


BURNS.    COMPLICATIONS. 


659 


served.  Bronchitis  and  pneumonia  often 
resiilt  either  from  inhalations  or  indi- 
rectly from  surface  burns.  Congestion 
in  the  kidney  has  been  noted,  with  re- 
sulting albuminuria  or  hsemoglobinuria, 
while  in  many  cases  the  urine  becomes 
exceedingly  scanty.  Autopsies  have 
shown  rupture  of  the  diaphragm  and 
stomachy  accompanied  by  contraction  of 
the  bladder.  Amyloid  degeneration  in 
the  viscera  has  been  noted  after  pro- 
longed siippuration.  Inflammation  of 
the  gastro-intestinal  tract  with  the  for- 
mation of  an  ulcer  (usually  one,  but  more 
rarely  several)  of  the  duodenum  (at  its 
pyloric  end)  frequently  occurs.  This 
ulceration  may  begin  early  (four  or  five 
days)  or  it  may  be  delayed  for  weeks, 
although,  without  the  appearance  of  rec- 
tal hEemorrhage  or  perforation,  with  con- 
sequent peritonitis,  we  have  no  means  of 
determining  its  presence.  At  times  this 
inflammation  extends  to  the  colon  and 
causes  diarrhoea.  Burns  affecting  either 
the  chest  or  abdomen  are  the  inducing 
cause,  although  severe  burns  at  other 
points  may  produce  them.  Septicaemia, 
pyeemia,  or  erysipelas  (the  streptococci 
being  found  after  death  in  the  blood) 
may  be  the  fatal  ending. 

Autopsies  on  the  bodies  of  five  small 
children  who  had  died  of  severe  burns: 
The  most  noticeable  gross  lesions  were 
cloudy  swelling  of  the  liver  and  kidney, 
acute  swelling  of  the  spleen,  and  swell- 
ing and  congestion  of  the  lymphatic 
glands  and  other  lymphatic  tissue.  Mi- 
croscopically the  most  interesting  lesions 
noted  were  parenchymatous  degeneration 
of  the  kidneys  and  liver,  focal  areas  of 
necrosis  in  the  liver,  and  pronounced 
focal  necrosis  in  the  lymphatic  tissue. 
The  lymphatic  tissue  was  affected 
throughout  the  body.  The  Malpighian 
corpuscles  of  the  spleen,  the  tonsils,  the 
gastric  lymphatic  follicles,  the  enteric, 
solitary,  and  agminated  follicles,  and  the 
lymphatic  glands,  all  showed  essentially 
the  same  changes.    The  lymphatic  glands 


were  much  swelled  and  at  times  con- 
gested. The  earliest  changes  were  in  the 
follicles,  and  consisted  of  an  oedematous 
swelling.  This  was  more  marked  toward 
the  centre  of  the  follicle.  In  areas  of 
less  advanced  alteration  the  lymphocytes 
«ere  merely  less  closely  packed  together 
than  is  usual,  but  in  the  areas  of  more 
marked  change  the  lymphocytes  were 
swelled  and  their  nuclei  fragmented. 
The  focal  degeneration  in  the  lymphatic 
follicles  of  the  tonsil  and  of  the  stomach 
and  in  the  Malpighian  bodies  of  the 
spleen  is  essentially  similar  to  that  of 
tlie  follicles  of  the  lymphatic  glands.  In 
these  areas  of  degeneration  in  the  lym- 
phatic tissue  we  find  appearances  essen- 
tially similar  to  those  seen  after  the  in- 
jection into  the  body  of  various  bacterial 
and  other  toxalbuminous  substances. 
Tlie  lymphatic  glands  from  the  cases  cf 
skin-burn  might  readily  be  mistaken  for 
the  lymphatic  glands  of  children  dead  of 
diphtheria.  The  lesions  in  the  other 
organs  are  also  essentially  similar  to 
those  found  in  the  bodies  of  persons  dead 
from  acute  infectious  diseases.  One  of 
the  main  causes  of  death  after  burns, 
therefore,  is  in  a  to.Ksemia  caused  by 
alterations  in  the  blood  and  tissues,  the 
direct  effect  of  the  elevations  of  tempera- 
ture. Bardeen  (Johns  Hopkins  Hosp. 
Bull.,  Apr.,  '97) . 

The  theories  of  the  causes  of  death 
from  bums  may  be  divided  into  four 
classes:  (I)  death  from  shock  or  extreme 
pain;  (2)  embolism,  thrombosis,  and 
destruction  of  the  blood-elements;  (3) 
pya^mic  infection  through  the  burned 
surface;  (4)  poisons  formed  by  the  ac- 
tion of  heat  on  the  tissues,  or  autoin- 
toxication from  deficient  excretion  by  the 
skin.  By  experimenting  upon  dogs  and 
rabbits  it  is  personally  claimed  that  the 
intoxication  theory  is  the  correct  one. 
Injection  of  large  quantities  of  artificial 
blood-serum  subcutaneously  appeared  to 
save  life  in  several  cases.  Azzarello 
(Giorn.  Ital.  delle  Mai.  Ven.  e  delle  Pelle, 
fase.  11,  '99). 

Two  sets  of  experiments  conducted  to 
determine  the  influence  of  the  skin  in 
producing  the  poisons  which  lead  to  a 
fatal  issue  in  burns,  from  which  it  is  con- 
cluded that  the  blood  itself,  rather  than 


660 


BURNS.     DIAGNOSIS. 


tlie  tissues,  is  the  seat  of  the  chemical 
change.  E.  Scholz  (Miincheiier  med. 
Woch.,  Jan.  30,  1900). 

1.  The  entire  pathological  picture 
presents  great  similarity  to  the  condi- 
tions found  in  the  diseases  characterized 
by  the  presence  of  toxins  of  bacterial 
origin  in  the  blood. 

2.  Damage  to  the  lymphatic  tissue  is 
a  constant  feature,  but  is  not  neces- 
sarily focal,  some  cases  presenting  only 
diffuse  degeneration.  The  cases  which 
live  but  a  few  hours  after  infliction 
seem  more  likely  to  present  a  focal  con- 
dition than  those  which  live  a  longer 
time,  as  the  condition  which  the  writer 
interprets  as  proliferation  and  phagocy- 
tosis is  one  which  may  very  rapidly  dis- 
appear. 

3.  The  focal  lesions  are  not  a  true 
necrosis,  but  rather  a  proliferation  of 
the  endothelial  cells  of  the  reticulum 
and  the  capillaries,  and  a  phagocytosis 
by  the  leucocytes  and  endothelial  cells, 
to  which  latter  is  due  the  fragmented, 
disintegrated  appearance  which  suggests 
a  true  necrosis.  John  McCrae  (Amer. 
Medicine,  Nov.  9,  1901). 

The  attempt  of  nature  to  restore  a 
covering  for  these  denuded  tissues  often 
results  unwisely.  Vicious  scars,  ad- 
hesions of  contiguous  parts  (causing 
webbed  fingers,  the  arm  being  attached 
to  the  side  by  granulations),  and  deform- 
ities may  be  encountered.  Cicatrices 
■may  be  small  and  flat  or  large  and 
rugous.  The  skin  may  be  as  soft  and 
ipliable  as  in  the  normal  state,  or  tightly 
stretched  and  drawing  the  parts  from 
their  anatomical  position.  Calcareous 
degeneration  or  even  epithelioma  may 
attack  the  scars.  Pressure  upon  the 
terminals  of  the  nerves  may  either  cause 
neuralgia  or  spasm  of  the  glottis,  which 
may  demand  surgical  interference  for  its 
removal.  Finally,  keloidal  tumors  may 
be  observed  as  a  consequence  of  vicious 
scarring.  They  will  not  differ  from 
those  produced  by  other  abnormalities 
and    will   accept   all   the   gyrations    en- 


countered in  other  conditions.  All  of 
the  scar  may  not  be  affected  with  keloid, 
as,  for  instance,  one  end  may  show  the 
prolongations,  while  the  other  resembles 
ordinary  cicatrices.  The  contractions  of 
the  skin  after  scarring  may  produce  great 
deformity  and  the  hand  may  be  drawn 
backward  upon  the  arm  or  talipes  cal- 
caneous  may  result  or  other  disfigura- 
tions too  numerous  to  mention  may  be 
shown.  Exposure  of  joints  has  taken 
place  followed  by  ankylosis.  Bones  have 
been  fractured  from  loss  of  substance 
(cooking  of  the  muscles). 

Siag^nosis. — Ordinarily  the  recognition 
of  burns  is  not  a  difficult  task,  although 
the  differentiation  of  the  varieties,  espe- 
cially of  the  second  and  third  degrees, 
may  demand  careful  examination.  Burn- 
ing flesh  with  destruction  of  its  particles, 
exposure  of  the  underlying  tissues  (mus- 
cles, bones,  etc.),  will  be  a  train  of  symp- 
toms not  to  be  controverted.  The  dif- 
ference between  burns  and  scalds  often 
may  occasion  difficulty,  but  the  fact  of 
the  greater  and  deeper  destruction  of  the 
former  with  the  more  superficial  char- 
acter of  the  latter  will  generally  be  suf- 
ficient. The  loss  of  hair  follows  the 
former  because  of  this  deep  destruction 
of  the  hair-follicle  and  papilla. 

Legal  aspects  of  burns.  In  cases  where 
the  persons  have  been  alive  when  they 
were  exposed  to  the  fire,  soot  is  found 
in  the  ramifications  of  the  trachea  and 
bronchi.  If  the  red  blood-corpuscles  are 
found  disintegrated  and  disfigured 
throughout,  then  this  is  a  further  sign 
of   a    person    having   been    burnt   while 

alive;  the  blood  of  animals  which  have 
been  burnt  or  scalded  after  death  shows 
only  occasionally  a  few  broken-up,  cre- 

nated,  or  polymorphous  red  corpuscles; 
as  a  rule,  the  red  blood-corpuscles  retain 
their  shape  and  integrity,  and  appear 
only  swelled  and  paler.  Robert  Neupert 
(Friedreich's  Bl.  f.  ger.  med.  u.  Sani- 
tsetspol,  vol.  xlviii,  pt.  3,  '97). 


BURNS.     PATHOLOGY. 


661 


The    diagnosis    of    death    from    burns 
cannot  be  made  solely  from  the  e.xtemal 
appearances.      Blisters    which    are    not 
filled     with     serum     arise     during     life. 
Bright-red  blood  of  charred  corpses  arises 
from   the   direct  physical   action   of   the 
heat   and   from    the   production   of   car- 
bonic-oxide hsemoglobin.     The   presence 
of  carbon  monoxide  in  the  blood  is  an 
almost   positive   proof    that   the    person 
during  life  was  not  exposed  to  the  influ- 
ence   of    fire.      The    finding    of    soot    or 
charred  material  in  the  respiratory  pas- 
sages is  certain  evidence  that  the  indi- 
vidual was  living  and  breathing  during 
and  in  the  presence  of  a  fire.     Lipkau 
(Deutsche  med.-Zeit.,  Aug.  13,  1900). 
Pathology. — The    condition    immedi- 
ately following  a  burn  is  that  of  dimin- 
ished blood-supply  to  the  part  attacked. 
This  seems  in  part  to  be  due  to  the  de- 
creased size  of  the  vessels,  probably  fol- 
lowing a  spasm  of  the  vasomotor  system. 
As  the  blood  is  prevented  entrance  into 
the  smaller  blood-vessels  there  is  a  con- 
sequent engorgement  of  the  viscera,  with 
actual  congestion  or  even  inflammation 
of  their  mucous  linings.     The  process 
does  not  end  here,  but  we  note  a  change 
in  the  corpuscular  elements  of  the  blood 
itself;    the  lumina  of  the  blood-vessels 
are    decreased,    which    allows    the    for- 
mation  of  thrombi   with  more   or  less 
complete  general  stasis  and  possibly  re- 
sulting in  a  cardiac  paralysis.    This  over- 
stimulation of  the  mucosae  may  account 
for  the  degenerate  changes  which  have 
been  observed  in  the  abdominal  viscera, 
ending,  as  stated,  in  the  formation  of 
ulcerations  of  the  duodenum  or  which 
have  caused  the  extension  of  the  inflam- 
mation to  the  colon  and  terminate  in 
the  production  of  diarrhoea  and  hfemor- 
rhage.     Thus  the  mode  of  death  is  ap- 
parently due  in  some  cases  to  the  forma- 
tion  of  pulmonary  thrombi   which   oc- 
casion this  paralysis  of  the  heart.    Other 
cases  probably  end  in  narcotic  poisoning 
from  absorption  of  the  dead  epithelium 


or  from  the  burned  clotliing  or  other 
adhered  materials. 

The  gases  of  the  blood  diminish 
markedly.  The  organism  of  burned  per- 
sons manufactures  toxins  in  large  quan- 
tity and  of  characteristically  noxious 
quality.  E.oger  and  Guinard  (La  Se- 
maine  Med.,  Nov.  3,  '94). 

The  cause  of  death  from  severe  burns 
is  intoxication  by  pathological  cleavage- 
products  of  the  body-proteids,  which  are 
caused  to  break  up  into  abnormal  and 
poisonous  compotmds.  Their  presence  in 
the  urine  is  of  grave  prognostic  import, 
for  one  of  the  cases  did  not  appear  at 
first  to  be  of  great  severity,  although  it 
terminated  in  death.  Sigmund  Fraenkel 
and  Spiegler  (Wiener  med.  Blatter,  No. 
5,  '97). 

Of  the  theories  that  have  been  held  as 
to  the  cause  of  death  in  eases  of  burns, 
Sonnenburg's  is  the  most  probable:  that 
of  a.  reflex  lowering  of  the  vascular  tone, 
with  consequent  cardiac  paralysis;  but 
parenchymatous  changes  and  degenera- 
tions in  the  kidneys,  Kings,  brain,  etc., 
are  to  be  taken  into  account.  Case  in 
which  numerous  streptococci  were  found 
in  the  blood  after  death,  this  showing- 
that  burns  should  be  treated  with  strict 
regard  for  antisepsis.  Tsehmarke  (Cent, 
f.  Chir.,  July  10,  '97).. 

After  examining  the  blood  in  ten  cases 
the  writer  records  the  following  points; 
The  blood  flows  sluggishly,  and  is  of  a 
peculiar  dark,  purple  appearance.  An 
immediate  increase  in  the  number  ot 
erythrocytes,  in  severe,  but  not  fatal, 
cases,  of  from  1,000,000  to  2,000,000  per 
cubic  millimetre,  takes  place  within 
a  few  hours;  in  fatal  cases,  of  from 
2,000,000  to  4,000,000  per  cubic  milli- 
metre. A  rapidly  increasing  leucoeytosis 
constantly  occurs, — in  cases  ending  in 
recovery  often  of  30,000  or  40,000  per 
cubic  millimetre ;  in  fatal  cases  usually 
above  50,000  per  cubic  millimetre. 
Morphological  changes  in  the  erythro- 
cytes are  slight.  The  percentage  of 
neutrophiles  is  somewhat  above  the 
normal,  but  not  so  much  as  in  the 
ordinary  inflammatory  leucoeytosis.  A 
considerable  destruction  of  the  leuco- 
cytes takes  place,  especially  in  very 
severe  burns.     Myelocytes  may  be  pres- 


662 


BURNS.    PROGNOSIS.    TREATMENT. 


ent  in  small  numbers  in  severe  cases. 
There  is,  as  a  rule,  marked  increase  in 
the  nimiber  of  blood-plates.  E.  A.  Locke 
(Boston  Med.  and  Surg.  Jour.,  Oct.  30, 
1902). 

Prognosis. — The  termination  of  tliis 
class  of  injuries  is  often  of  serious  import 
especially  when  medico-legal  questions 
arise.  This  should  be  determined  by  the 
several  factors  which  arise  in  each  case. 
Consideration  must  be  given  to  indi- 
viduality of  the  sufferer,  both  his  age 
and  constitutional  acquirements;  the  ex- 
tent of  the  burn,  both  as  to  surface  and 
depth  involved;  the  location  of  the  in- 
jury, and  the  nature  of  the  exciting 
medium.  The  effects  upon  strong,  ro- 
bust subjects  are  not  so  marked  as  upon 
those  of  weaker  constitutions,  and,  while 
the  same  degree  or  extent  of  burn  will 
soon  be  recovered  from  by  the  former, 
the  most  dire  results  may  follow  in  the 
latter  persons.  Thus  it  may  be  noticed 
that  burns  among  machinists,  glass- 
blowers,  plumbers,  and  foundrymen  will 
not  be  so  serious  as  would  the  same  de- 
gree or  extent  among  clerks  or  those 
engaged  in  gentlemanly  pursuits.  Col- 
ored persons  suffer  less  severely  than  do 
the  white.  Females,  on  account  of  more 
delicate  systems,  are  less  able  to  resist 
shock  than  are  the  males.  Middle  life 
is  not  so  severely  affected  as  are  children 
or  aged  people.  Some  persons  may  be 
able  to  resist  the  shock  only  to  be  car- 
ried off  by  the  complications  that  arise. 

Surface  involvement  seems  to  exert  a 
greater  depression  or  fatality  than  does 
depth  of  tissue.  A  burn,  even  of  the  first 
degree,  which  occupies  an  extended  area 
and  those  of  the  second  may  terminate 
fatally  if  one-fourth  or  one-third  of  the 
superficial  parts  are  involved;  a  fatal 
issue  may  also  occur  in  burns  occupying 
one-half  of  the  body-surface.  A  burn  of 
the  second  degree  which  occupies  only  a 
limited  extent  of  surface,  but  which  de- 


stroys the  epidermis  entire,  may  end  in 
recovery,  while  those  of  the  third  may, 
through  their  deep  involvement,  produce 
complications  with  which  we  are  unable 
to  combat.  Burns  occupying  the  abdo- 
men give  the  highest  mortality,  while 
those  of  the  thorax  are  only  second  to  a 
slightly  minor  extent;  but  those  of  the 
head,  neck,  and  limbs  prove  fatal  in 
many  instances. 

[Of  26  cases  seen  by  Sajous  after  a 
boiler  explosion,  on  the  Lake  of  Geneva, 
in  1892,  22  died  within  a  few  hours  after 
the  accident,  although,  with  few  excep- 
tions, the  scalds,  though  involving  the 
greater  part  of  the  body,  did  not  reach 
beyond  the  epidermic  layer,  excepting 
over  the  face  and  hands.     Ed.] 

Of  the  298  men  killed  or  injured  on  the 
Japanese  side  of  the  Battle  of  the  Yalu, 
a  large  number  had  received  burns  cover- 
ing an  area  of  more  than  one-third  of  the 
body.  Only  2  out  of  the  57  cases  of  this 
class  recovered.  Susuki  (Boston  Med. 
and  Surg.  Jour.,  Dec.  9,  '97). 

The  nature  of  the  exciting  medium 
often  governs  the  termination  of  burns, 
and  those  produced  by  cohesive  bodies 
cause  the  greater  destruction  of  part  or 
life.  The  length  of  time  required  for  the 
partial  or  complete  reparation  of  the  sur- 
face may  be  an  important  question  in 
medico-legal  cases.  This  can  only  be 
governed  by  the  type  of  injury,  the 
length  of  contact  of  the  exciting  agent, 
the  nature  of  the  affected  person,  and 
the  general  aspects  of  the  case  in  ques- 
tion. 

Treatment. — Constitutional.  — The 
constitutional  treatment  is  to  be  directed 
toward  the  relief  of  pain,  the  restoration 
of  the  depressed  vitality  at  the  time  of 
accident,  —  i.e.,  sustaining  the  system 
throughout  the  entire  restorative  proc- 
ess. Pain  is  best  relieved  by  opium,  or 
its  alkaloid,  morphine  (preferably  by 
hypodermic  injection),  because  these 
agents  have  little,  if  any,  depressing  ac- 


BURNS.    TREATMENT. 


663 


tion  upon  the  cardiac  functions.  The 
dose  required  will  be  much  greater  than 
ordinarily  used,  because  of  the  sudden 
character  and  great  amount  of  depres- 
sion in  these  injuries. 

Vitality  must  be  restored  as  quickly 
as  possible,  and  the  use  of  ammonia 
(preferably  carbonate),  strychnine,  and 
caffeine  (because  of  their  stimulating 
effect  upon  the  cardiac  muscle);  hot 
drinks,  such  as  milk  and  tea;  alcoholic 
drugs  in  the  form  of  whisky  or  brandy, 
and  the  production  of  local  or  gener- 
alized sweating.  A  most  desirable  plan 
of  restoring  heat  is  by  using  hot-water 
bottles  placed  at  regular  points  so  as  to 
diffuse  its  effects.  Other  means,  as,  for 
instance,  covering  the  body  with  a  sheet 
and  conveying  heat  through  a  pipe  or 
by  placing  heated  bricks  beneath  this 
covering.  To  keep  the  sufferer  fairly 
comfortable  during  the  local  treatment 
stimulation  must  be  kept  up,  care  being 
taken  not  to  produce  overactivity  and 
thus  allow  reaction  to  prove  as  deleteri- 
ous as  the  effect  of  the  burn. 

The  functions  of  the  body  must  be 
regulated,  the  bowels  being  kept  free  or 
confined,  according  to  the  conditions 
present;  the  action  of  the  kidneys  should 
be  watched.  In  some  cases  it  may  be 
wise  to  anaesthetize  the  patient  during 
the  first  few  hours  immediately  follow- 
ing the  burn,  and  especially  during  the 
first  dressings  of  aggravated  cases. 

Local. — The  local  treatment  is  to  be 
directed  toward  the  limitation  of  the  re- 
sulting inflammation,  the  prevention  of 
septic  infection,  assisting  the  normal 
elimination  of  the  eschar,  the  develo]i- 
ment  of  granulations,  and  limitation  of 
the  deformity. 

In  burns  of  the  first  degree  little  or 
no  treatment  may  be  demanded.  In 
the  more  aggravated  cases  of  this  type 
the  application  of  home  measures,  such 


as  bicarbonate  of  sodium,  the  white  of 
egg  and  sweet  oil  (equal  parts),  lead- 
water  and  laudanum,  and  the  various 
hot  or  cold  means  generally  at  the  dis- 
posal of  housewives. 

Burns  of  the  second  and  third  degrees 
must  be  more  strenuously  treated.  It 
is  often  a  difficult  problem  to  know 
which  is  the  more  soothing  application 
to  be  advised  and  from  which  we  may 
get  the  better  result.  In  one  case  hot 
applications,  in  another  cold;  in  some 
wet,  and  in  others  dry,  measures  are  to 
be  given.  The  vesicles,  if  numerous, 
should  be  untouched;  but  if  only  a  few, 
they  are  best  evacuated. 

Prof.  S.  D.  Gross  was  wont,  in  many 
mild  and  severe  cases,  to  use  ordinary 
white-lead  paint;  the  results  achieved 
were  often  marvelous. 

[This  is  a  remarkably  efficacious  meas- 
ure. Mere  paintiug  of  the  burn,  as  if  it 
were  an  article  of  furniture,  etc.,  causes 
immediate  cessation  of  the  pain.     Ed.] 

The  use  of  carbolized  vaselin  (15  to 
30  grains  to  the  ounce),  watery  solutions 
of  carbolic  acid  (about  20  grains  to  the 
ounce),  subnitrate  of  bismuth  (V2  to  1 
drachm  to  ounce  of  ointment  of  zinc 
oxide  or  petrolatum),  boric  acid  (either 
in  watery  saturated  solutions  or  oint- 
ments of  either  zinc  oxide  or  petrolatum 
in  strengths  varying  from  ^/,  to  2 
drachms  to  the  ounce),  bicarbonate  of 
soda  in  almost  full  strength  (in  ointment 
or  watery  solutions),  and  starch  in  vary- 
ing proportions  will  usually  be  found 
very  efficacious. 

Turpentine,  where  granulations  are 
sluggish,  will  give  excellent  results  used 
either  in  full  or  diluted  strengths,  giv- 
ing care  not  to  produce  too  much  stimu- 
lation. H.  L.  Mclnnis  states  that  spirit 
of  turpentine  applied  to  a  burn  of  either 
the  first,  second,  or  third  degree  almost 
at  once  relieves  the  pain,  while  the  burn 


664 


BURNS.    TREATMENT. 


heals.  After  wrapping  a  thin  layer  of 
absorbent  cotton  over  the  burn,  the  cot- 
ton is  saturated  with  common  turpen- 
tine and  covered  with  bandages.  Being 
volatile,  the  turpentine  evaporates,  and 
it  is  therefore  necessary  to  keep  the  cot- 
ton moistened  with  it.  When  there  are 
large  vesicles,  these  are  opened  on  the 
second  or  third  day.  It  is  best  to  keep 
the  spirit  off  the  healthy  skin  if  possible 
to  avoid  the  local  irritation. 

Turpentine  applied  to  a  burn  of  either 
the  first,  second,  or  third  degree  will  al- 
most at  once  relieve  the  pain.  The  burn 
heals  very  rapidly.  It  is  applied  as  fol- 
lows: After  wrapping  a  thin  layer  of 
absorbent  cotton  over  the  burn  it  is 
saturated  with  the  turpentine  and  band- 
aged. The  common  eonmiereial  article 
found  in  every  house  is  sufficient.  H.  L. 
Mclnnes  (Brit.  Med.  Jour.,  Sept.,  '96). 

Surgery  of  this  day  has  placed  many 
excellent  antiseptics  at  our  disposal,  and 
there  is  no  better  application  than  bi- 
chloride of  mercury  in  the  proportion  of 
1  or  more  grains,  preferably  the  former, 
to  1000  parts  of  water  and  kept  in  con- 
stant contact,  the  dressings  being  made 
without  removing  the  former  cloths. 

Ichthyol  in  watery  solutions  (1  or 
more  drachms  to  the  ounce),  or  in  glyc- 
erin similar  strength),  or  even  in  oint- 
ment form  (with  zinc  oxide  or  petrola- 
tum, about  1  to  3  drachms  to  the  ounce) 
and  the  iodine  derivatives,  such  as  iodol, 
aristol,  europhen  (given  preferably  in 
ointment,  15  to  30  grains  to  the  ounce 
of  petrolatum  or  lard)  are  reliable  meas- 
ures. 

Ichthyol  is  efficacious  in  treatment  of 
burns  of  the  first  and  second  degrees. 
It  allays  the  pain  at  once  and  slight 
superficial  burns  heal  rapidly.  In  burns 
of  the  second  degree  with  the  formation 
of  bulla,  even  when  extensive  areas  are 
involved,  the  remedy  also  acts  favor- 
ably.    It  is  used  dry,  diluted  with  zinc 


oxide  or  bismuth,  the  powder  being 
spread  evenly  over  the  surface;  in  oint- 
ment (10  to  30  per  cent.)  ;  or  as  a  com- 
bination of  these  two  methods.  The 
powder  is  the  most  satisfactory  form 
in  extensive  burns  of  the  first  degree, 
and  should  be  plentifully  applied.  In 
extensive  burns  of  the  second  degree 
the  soft  paste  is  preferable. 

The   zinc-oxide   powder   may  be   com- 
bined as  follows: — 
1}  Zinc  oxide,  20  parts. 

Carb.  magnes.,  10  parts. 

Ichthyol,  1  to  2  parts. 
While  the  paste  is  mixed  as  follows : — 
IJ  Carbonate  of  lime,  10  parts. 

Zinc  oxide,  5  parts. 

Oil,  10  parts. 

Lime-water,    10  parts. 

Ichthyol,   1   to  3  parts. 
Leistikow     (Monat.    f.    prak.    Derm., 
Nov.  1,  '95). 

Ichthyol  used  in  eases  of  severe  burns 
with  remarkable  success.  It  is  applied 
pure  and  in  a  rather  thick  layer,  talcum 
powder  being  then  liberally  sprinkled  on 
it,  and  plenty  of  cotton  batting  applied, 
the  whole  being  fixed  in  place  by  means 
of  a  strip  of  soft  material.  The  bandage 
should  not  be  renewed.  After  three  or. 
five  days  it  is  removed.  If  the  contents 
of  large  vesicles  are  gelatinous,  or  if  the 
vesicles  are  already  cracked,  it  is  neces- 
sary to  remove  the  detritus  before  ap- 
plying the  ichthyol. 

Disinfection  is  entirely  unnecessary. 
Should  the  bandage  have  become  wet 
through  from  excessive  secretion  on  the 
second  day,  it  should  be  removed,  and  a 
new  application  of  ichthyol  with  fresh 
cotton  be  made.  Fr.  E.  Mueller  (Aerztl. 
Rundseh.,  No.  21,  '99). 

Thiol  has  been  found  useful  for  all 
degrees  of  burn.  According  to  Bidder, 
it  allays  pain  very  rapidly  and  arrests 
cutaneous  hyperemia.  In  this  manner 
it  tends  to  prevent  ulceration  and  scar- 
ring. 

Thiol  especially  valuable  in  burns  of 
the  second  degree.  Suppuration  and 
cicatrices  are  avoided  even  after  burns 
of  the   third   and  fom-th  degrees.     The 


BURNS.    TREATMENT. 


665 


parts  are  first  washed  with  a  weak  anti- 
septic solution,  and  the  cuticle  that  may 
be  hanging  loose  from  ruptured  blisters 
is  removed,  taking  care  to  leave  intact 
those  that  have  not  opened.  After 
dusting  the  burn  with  boric  acid  the 
entire  surface  of  the  burned  region  and 
the  skin  around  it  are  painted  with  a 
solution  of  equal  parts  of  thiol  and  pure 
water.  A  layer  of  greased  cotton  is 
then  laid  on  the  burn,  and  kept  in  place 
with  a  loose  bandage.  Giraudon  (These 
de  Paris,  '95). 

Aristol — which  occurs  in  crystals  of  a 
light-reddish-brown  color,  soluble  in 
water,  slightly  soluble  in  alcohol,  and 
freely  soluble  in  ether  and  fats — is 
another  valuable  agent  in  burns  of  the 
second  and  third  degrees,  and  has  been 
found  strikingly  effective  where  other 
remedies  have  failed. 

Pain  is  almost  instantly  relieved  and 

healing  is  rapid.     Haas   (Deutsche  med. 

Woch.,  p.  783,  '94). 

It  may  be  used  in  the  form  of  powder 
or  mixed  with  oil  or  vaselin.  The  sur- 
face should  be  disinfected  with  a  boric- 
acid  lotion,  and  after  opening  the  vesi- 
cles aristol  is  applied  and  the  whole  is 
covered  with  sterilized  cotton-wool, 
gutta-percha  paper,  and  a  bandage.  The 
application  of  aristol  powder  directly  to 
the  wound  at  the  beginning  hinders  the 
dressing  from  soaking  up  the  secretion; 
when  the  latter  has  diminished,  how- 
ever, aristol  may  be  applied  either  alone 
or  in  a  10-per-cent.  ointment  with  olive- 
oil,  vaselin,  and  lanolin. 

Aristol  is  of  great  service  in  the  treat- 
ment of  scalds  and  burns.  After  a 
thorough  disinfection  and  cleansing  of 
the  burned  area,  and  the  opening  of  the 
vesicles,  a  dressing  is .  applied  of  aristol 
salve,  smeared  upon  sterilized  gauze  in  a 
layer  of  about  the  thickness  of  a  knife- 
blade,  and  this  dressing  is  changed  daily. 
The  dressing  is  covered  with  cotton,  and 
held  in  place  with  gauze  bandages.  In 
personal  cases,  at  first  an  aristol  salve, 
consisting  of  5  grammes;    ol.   olivse,   10 


grammes;  lanolin,  40  grammes,  was  ap- 
plied, and,  when  the  wound  surface  had 
become  smaller  and  granulations  had 
formed,  aristol  powder  was  dusted  on, 
and  covered  with  gauze  and  cotton. 
Edward  Roelig  (Deutsche  med.-Zeit., 
No.  56,  '99). 

Of  late  the  French  surgeons  have 
lauded  picric  acid  used  in  saturated  solu- 
tions with  water  (increasing  the  solubil- 
ity by  means  of  the  addition  of  1  ounce 
of  alcohol,  as  the  acid  is  soluble  to  the 
extent  of  only  2  drachms  to  the  quart 
of  water).  They  claim  that  it  is  par- 
ticularly useful  for  the  relief  of  pain 
and  that  it  greatly  assists  the  formation 
of  granulations.  I  can  subscribe  to  both 
of  these  statements,  as  many  excellent 
results  have  followed  its  use  in  my 
hands. 

A  remedy  for  burns  must  be  analgesic, 
antiseptic,  and  also  keratogenous :  three 
qualities  possessed  by  picric  acid  in  so- 
lution of  1  to  200.  Its  use  is  also 
free  from  accidents  sometimes  caused 
by  antiseptics.  Filleul  (L'Union  Pharm., 
Deo.,  '95). 

Picric  acid  employed  extensively,  using 
a  solution  made  by  dissolving  1  Vj 
drachms  of  picric  acid  in  3  ounces  of 
alcohol,  which  is  then  diluted  with  2 
pints  of  distilled  water,  a  saturated  solu- 
tion being  thus  procured. 

The  clothing  over  the  injured  part 
should  be  gently  removed,  and  the  burnt 
or  scalded  portion  should  be  cleaned  as 
thoroughly  as  possible  with  a  piece  of 
absorbent  cotton-wool  soaked  in  the 
lotion.  Blisters  should  be  pricked,  and 
the  serum  should  be  allowed  to  escape, 
care  being  taken  not  to  destroy  the  epi- 
thelial surfaces.  Strips  of  sterilized 
gauze  are  then  soaked  in  the  solution  of 
picric  acid,  and  are  so  applied  as  to  cover 
the  whole  of  the  injured  surface.  A  thin 
layer  of  absorbent  cotton-wool  is  put 
over  the  gauze,  and  the  dressing  is  kept 
in  place  by  a  light  linen  bandage.  The 
moist  dressing  soon  dries,  and  it  may  be 
left  in  place  for  three  or  four  days.  It 
must  then  be  changed,  the  gauze  being 
thoroughly   moistened   with   the   picric- 


666 


BURNS.    TREATMENT. 


acid  solution,  for  it  adheres  very  closely 
to  the  skin.  The  second  dressing  is  ap- 
plied in  exactly  the  same  manner  as  the 
first,  and  it  may  be  left  on  for  a  week. 

The  great  advantages  of  this  method 
of  treatment  are:  First,  that  the  picric 
acid  seems  to  deaden  the  sense  of  pain; 
and,  secondly,  that  it  limits  the  tendency 
to  suppuration,  for  it  coagulates  the 
albuminous  exudations,  and  healing 
takes  place  under  a  scab  consisting  of 
epithelial  cells  hardened  by  picric  acid. 
A  smooth  and  supple  cicatrix  remains, 
which  is  as  much  superior  to  the  ordi- 
nary scar  from  a  burn  as  our  present 
surgical  sear  is  superior  to  that  obtained 
by  our  predecessors,  who  allowed  their 
wounds  to  granulate.  D'Arey  Power 
(Medico-Surg.  Bull.,  Feb.  10,  '97). 

Personal  experience  in  fifty  cases  has 
shown  that  it  is  advisable  to  let  the 
shreds  of  clothing  which  have  been 
burned  into  the  skin  remain  until  the 
second  dressing;  the  cloth  having  been 
asepticized  by  burning,  it  will  do  no 
harm  by  remaining,  while  removal  can 
only  be  accomplished  by  stripping  away 
the  flesh.  The  cloth  will  act  as  a  capil- 
lary drain  into  the  skin  and  it  will  pro- 
mote a  permeation  of  the  acid  solution 
into  the  injured  tissue.  At  a  second 
dressing  the  thoroughly-soaked  fibres 
can  be  more  easily  removed.  Dressings 
soaked  in  picric-acid  solution  do  not  ad- 
here as  much  as  other  applications. 
Thompson  (St.  Louis  Med.  Review,  Feb. 
20,  '97). 

Picric  acid  is  only  useful  in  burns  of 
first  and  second  degrees,  its  particular 
action  being  to  stimulate  the  growth  of 
epidermis.  It  allays  pain.  In  burns  of 
tlie  third  degree  it  checks  suppuration, 
but  does  not  hasten  granulation.  C. 
Willems  (Ann.  de  la  Soc.  Beige  de  Chir., 
May  15,  '98). 

The  best  topical  application  to  hasten 
cicatrization  in  burns  is  picric  acid.  Its 
application  is  recommended  from  super- 
ficial burns  to  those  of  the  third  de- 
gree. It  is  contra-indicated  in  deep, 
old,  or  suppurating  burns,  and  in  very 
young  children.  Technique  consists  of 
antiseptic  cleansing  of  the  burn  in  a 
picric-acid  bath  of  1  per  cent.,  with  a 
careful    preservation    of    the    epidermis. 


This  washing  is  to  be  repeated,  taking 
all  possible  care  to  prevent  raising  the 
epidermis.  When  bums  are  very  super- 
ficial, remarkable  cures  have  been  ef- 
fected by  painting  with  ether  or  alcohol 
saturated  with  picric  acid.  Dakhyle  (Le 
ProgrSs  M6d.,  Jan.  7,  '99). 

The  combination  of  picric  and  citric 
acids,  which  Esbach  devised  for  the  de- 
tection of  albumin,  is  more  effective  than 
the  picric  acid  alone,  in  burns  of  the 
second  degree. 

Esbach's  solution  consists  of  10  parts 
of  picric  acid,  20  of  citric  acid,  and  1000 
of  water.  Without  any  elaborate  at- 
tempts at  antisepsis  the  bullae  and  vesi- 
cles should  be  opened  with  a  clean  blade 
and  the  fluid  applied  freely,  care  being 
taken  that  the  solution  reaches  the  in- 
terior of  each  one.  The  combination 
after  the  first  smart  has  passed  removes 
the  pain  very  quickly.  After  the  excess 
of  fluid  has  drained  oflf  the  part  may  be 
covered  with  tissue  or  soft  gauze  and 
left  undisturbed  for  several  days.  After 
two  or  three  days  the  fluid  should  be 
reapplied  to  such  areas  as  are  moist  and 
the  part  carefully  recovered.  E.  M. 
Alger  (Ther.  Gaz.,  June  15,  '99). 

For  burns  in  infancy  and  children  the 
best  application  is  a  1-per-cent.  aqueous 
solution  of  picric  acid.  This  gives  al- 
most immediate  relief  from  pain,  and 
healing  takes  place  rapidlj'.  After  the 
burned  area  has  been  coated  once  or 
twice  with  the  solution  a  thin  laj'er  of 
absorbent  cotton  may  be  applied  dry, 
and  over  this  a  layer  of  impervious  tis- 
sue, and,  finally,  as  much  cotton  as  may 
be  required  for  warmth,  protection,  ex- 
clusion of  air  and  germs,  and  over  this 
a  loose  bandage.  Charles  Warren  Allen 
(Pediatrics,  Mar.  15,  1901). 

Some  French  observers  also  claim  that 
it  is  not  poisonous,  and  that,  excepting 
its  effect  upon  the  urine,  which  it  turns 
very  yellow,  it  has  no  other  bad  effects; 
but  negative  evidence  has  been  adduced, 
however,  and  several  cases  of  poisoninfj 
(smarting  at  the  part  of  application, 
with  the  production  of  vomiting  in  tlie 
course  of  twenty-four  hours)  have  been 


BURNS.    TREATMENT. 


G67 


recorded  by  Walther,  Berger,  Labouche, 
Tuffier,  and  others.  Colic,  diarrhoea, 
yellowish  discoloration  of  the  skin,  sleep- 
iness, and  scanty,  dark-colored  urine 
were  the  main  symptoms. 

Calcined  magnesia  is  a  valuable  agent 
for  the  treatment  of  burns  of  the  first 
and  second  degrees. 

The  affected  parts  are  covered  with   a 
thick  layer  of  a  paste,  which  is  prepaicd 
by  mi.xing  the  calcined  magnesia  with  a 
certain   quantity   of  water.     This   paste 
is  allowed  to  dry  on  the  akin,  and  when 
it  becomes  detached  and  falls  off  it  is  re- 
placed by  a  fresh  application.    Very  soon 
after  the  paste  is  applied  the  pain  ceases, 
and  under  the  protective  covering  formed 
by    the    magnesia    the    wounds    recover 
without  leaving  the  cutaneous  pigmenta- 
tion which  is  so  often  observed  to  fol- 
low  burns   that   have   been   allowed   to 
remain    exposed    to    the    air.      Vergely 
(Revue  M6d.,  Feb.  10,  '96). 
Iodoform  is  anaesthetic  and  antiseptic. 
It  may  be  left  in  situ  for  a  considerable 
period — a    week — without    necessitating 
a  change  of  dressing.     It  should  not  be 
strewn  upon  the  raw  coriiim  nor  upon 
granulating  tissues. 

After  accidents  by  burning,  and  par- 
ticularly where  the  surface  of  the  skin 
destroyed     has     been     very     extensive, 
atrophy  of  the  optic  nerves  has  resulted. 
It  is  also  known  that  iodoform  is  capa- 
ble  of  giving  rise   to   a  form   of   toxic 
amblyopia,  resembling  somewhat  closely 
that   produced   by   alcohol    or    tobacco. 
Whether  these  eye-symptoms  are  due  to 
the  burn  in  all  cases,  or  to  absorption  of 
iodoform    (and  similar   substances)    ap- 
plied to   the  wound,   the   possibility   of 
the   occurrence   of   a  condition  so  very 
serious    ought    to    be    borne    in    mind. 
Terson  .(Arch.  d'Opht.,  Oct.,  '97). 
Nitrate  of  potassium,  or  nitre,  has  been 
found  to  be  useful  in  all  kinds  of  burns, 
and  may  be  employed  to  great  advantage 
when  the  other  agents  described  cannot 
be  had.     It  acts  mainly  as  a  refrigerant 
by  causing  notable  lowering  of  the  tem- 
perature of  the  liquid  used  as  solvent. 


If  a  burned  hand  or  foot  is  plunged 
into  a  basin  of  water  to  which  a  few 
spoonfuls  of  the  nitrate  have  been  added, 
the  pain  ceases  rapidly;  if  the  water  be- 
comes slightly  heated,  the  pain  retui-ns, 
but  it  is  allayed  as  soon  as  a  fresh  quan- 
tity of  the  salt  is  added.  This  bath, 
which  is  prolonged  fi'om  two  to  three 
hours,  may  bring  about  the  definitive 
disappearance  of  the  pain  and  even  prs- 
vent  the  production  of  blisters.  The  ap- 
plication of  the  compresses  also  exercises 
the  same  influence.  By  this  means  tlie 
pain  is  allayed  and  cicatrization  takes 
place  without  delay.  Poggi  (Revue 
M6d.,  Feb.   16,  '96). 

Any  complication,  such  as  bleeding, 
of  small  or  large  vessels,  must  be  checked 
by  appropriate  surgical  measures.  Sep- 
sis must  be  prevented  by  the  early  re- 
moval of  any  obnoxious  material.  Parti- 
cles of  dead  skin  laying  over  the  surface 
are  to  be  removed,  clothing  if  present, 
if  that  can  be  accomplished  without 
any  further  destruction  of  the  tissues, 
thereby  exposing  the  healthy  parts,  or 
producing  pain  to  the  sufferer. 

Emphasis  upon  the  great  importance 
of  keeping  the  injured  part  aseptic;  the 
patient  may  recover  from  the  shock  only 
to  die  of  blood-poisoning.  This  is  espe- 
cially to  be  feared  where  the  side  of  the 
face  and  the  chest  are  extensively  burnt. 
The  wound  should  be  at  once  thoroughly 
disinfected.  It  is  then  covered  with  sub- 
nitrate  of  bismuth,  and  then  with  iodo- 
form gauze,  kept  in  place  by  light  band- 
ages. Tschmarke  (Deutsche  Zeit.  f. 
Chir.,  vol.  xliv,  pp.  346-392,  '97). 

The  fatal  result  in  severe  burns  is  due 
to  the  absorption  of  a  toxic  substance 
derived  from  chemical  changes  in  the 
burnt  tissues.  The  lethal  tendency  is 
best  met  by  removing  the  necrosed  tis- 
sues and  infusing  saline  solution.  Three 
cases  of  very  severe  burns  in  which  the 
patients  were  in  a  most  critical  condi- 
tion, with  stupor,  suppression  of  urine, 
etc.,  in  which  recovery  followed  as  a  re- 
sult of  this  method.  The  infusion  was 
repeated  daily  for  several  days.  Para- 
scandolo  (Centralb.  f.  Chir.,  Apr.  27, 
1901). 


668 


BURNS.     TREATMENT. 


Calcium  liypochloride  an  excellent 
antiseptic.  It  is  not  largely  used  for 
burns,  and  therefore  attention  is  called 
to  the  good  results  which  have  been 
obtained  by  the  author.  Having  been 
dissatisfied  with  the  usual  methods  of 
treating  burns,  putting  up  one  foot  of 
a  smith,  who  had  been  burned  on  both 
feet,  with  calcium  hypochloride,  and  the 
*  other  one  with  oil  was  tried;  the  foot 
treated  with  the  calcium  healed  in  a 
fortnight,  while  the  other  took  four 
weeks.  A  cool  bandage  with  oil  is  now 
applied  on  the  first  day,  which  causes 
the  vesicles  to  form  quickly,  and  after 
twenty-four  hours  these  are  opened, 
under  antiseptic  precautions.  Com- 
presses steeped  in  the  solution  are  then 
applied,  and  this  is  renewed  after 
twenty-four  hours,  but  they  are  kept 
moist  by  pouring  on  fresh  solution  dur- 
ing that  time.  It  is  of  importance  to 
leave  the  compresses  on  as  long  as  pos- 
sible, and  to  keep  them  constantly 
damp.  Great  care  must  be  exercised 
in  removing  the  old  compresses  not  to 
disturb  the  scabs  under  which  the 
wound  is  to  heal.  The  solution  which 
the  author  uses  is: — 

B  Calc.  hypochlor.,  2.4  to  5  grammes 
(37   grains)    (circa). 
Aquae    destil.,    9.900    grammes    (35 
ounces) . 
Solve,  filtra,  et  adde: — 

Spt.     camphor.,     5     grammes     (85 
minims). 
E.  Tichy   (Deutsche  med.  Woeh.,  July 
17,  1902). 
Granulations  may  often  be  assisted  by 
powders  of  acetanilid  in  full  strength, 
dusted  over  the  surface,  or  by  the  use 
of  some  of  the  iodine  derivatives,  such 
as  iodol,  europhen,  or  aristol  (15  to  60 
grains  to  the  ounce  of  powdered  starch 
or  ointment),  applied  to  the  exposed  sur- 
face. 

Limitation  of  deformity  is  a  very  seri- 
ous problem.  Splints  are  to  be  placed 
so  as  to  prevent  the  parts  from  losing 
their  anatomical  relation  and  should  be 
kept  applied  for  some  time  after  the 
parts   have   healed   because    of   the    in- 


herent tendency  of  the  contraction  for 
long  periods,  even  years,  after  the  ap- 
parent cure.  Bandages  are  to  be  kept 
continuously  applied  to  prevent  con- 
tiguous surfaces  from  becoming  agglu- 
tinated. Massage  must  be  advised  at  the 
very  earliest  moment  so  as  to  restore  the 
pliability  of  the  part  and  prevent  anky- 
losis, when  a  joint  is  involved.  Even 
with  all  the  measures  that  we  can  adopt 
the  loss  of  skin-tissue  may  be  so  extensive 
that  skin-grafting  will  be  the  only  means 
with  which  we  can  hope  to  restore  the 
integrity  of  the  part.  The  relief  of  cica- 
trices or  contractions,  ankylosis,  or  press- 
ure upon  the  nerve-filaments  sometimes 
requires  the  most  energetic  siirgical  in- 
terference. 

Electrical  Burns. — Electrical  burns, 
according  to  Elder  (Montreal  Med.  Jour., 
Jan.,  1900),  from  contact  with  a  "live 
wire"  differ  greatly  in  their  behavior 
from  ordinary  burns.  At  first  the  clin- 
ical picture  is  very  much  that  of  moist 
gangrene  or  that  of  severe  frost-bites. 
The  pain  is  often  very  severe.  The  shock 
present  is  due  both  to  the  electrical  con- 
tact and  tO'  the  burn  per  se.  They  re- 
quire one  and  a  half  to  three  times  as 
long  for  recovery  as  ordinary  burns. 
The  sloughing  affects  principally  the 
muscles  and  blood-vessels,  and  the  blood 
does  not  appear  to  show  anj'  tendency  to 
clot  in  these  burns. 

Case  of  severe  burns  caused  by  an 
electric  current  of  2000  volts.  The  pa- 
tient, an  electrician,  23  years  old,  came 
in  contact  with  a  live  wire  and  received 
severe  burns  of  the  head,  chin,  right 
shoulder,  and  wrists.  The  burn  on  the 
head  was  followed  by  necrosis  of  the 
bone  and  suppuration  of  some  of  the 
gray  matter,  for  which  the  patient  was 
trephined.  After  a  protracted  illness 
the  man  made  a  good  recovery.  Lapsa- 
koff  (Bolnitchnaja  Gazeta  Botkina,  Oct. 
16,  1902). 
Treating  Electrical  Burns. — The  treat- 


CAJUPUT-OIL. 


669 


ment  found  most  ef&cacious  by  Elder 
(Montreal  Med.  Jour.,  Jan.,  1900)  is  to 
keep  the  limb  in  a  warm  carbolic-lotion 
bath  of  1  in  100  strength,  taking  pre- 
cautions against  the  possibility  of  the 
occurrence  of  secondary  hemorrhage.  If 
secondary  hemorrhage  occur,  or  when  a 
definite  line  of  demarkation  has  formed, 
the  necrosed  tissue  must  be  removed.  In 
many  cases  amputation  is  necessary,  but 
the  skin-flaps  should  not  be  closed,  be- 
cause large  masses  of  muscles  are  sure  to 
slough  away  subsequently.  The  wound 
should  be  allowed  to  granulate,  and  sub- 
sequently be  skin-grafted.  Immediately 
after  the  burn  hypodermic  injections  of 


morphine    (Vg    grain)    and    strychnine 
(V30   grain)   may   be   given   alternately. 
To  lessen  the  offensive  odor  the  1  in  100 
carbolic  lotion  may  be  replaced  by  a  bath 
of  1  in  10,000  perchloride  of  mercury. 
In  addition,  morphine,  phenaeetin,  caf- 
feine,   chloral-hydrate,    and    potassium 
bromide  may  be  administered  together. 
Treatment  of  electrical  burns  consists 
in  immobilization  of  the  part  and  pro- 
tection with  sterile  gauze,  and,  if  the 
burn  is  extensive,  skin-grafting.     Mally 
(Eevue  de  Chir.,  Mar.  10,   1900). 
J.  Abbott  Cantkell, 

Philadelphia. 

BTJTYL-CHLORAL.    See  Chloral. 


CADE.    See  Junipee. 
CAFFEINE.    See  Coffee. 

CAJUPUT-OIL.  —  This  is  a  bright- 
green,  mobile,  volatile  oil  had  by  dis- 
tillation from  the  leaves  of  the  Melaleuca 
leucadendron  {M.  cajuputi):  a  tree  in- 
digenous to  the  Orient.  It  has  a  strong 
camphoraceous  odor  and  aromatic,  bitter 
taste.  A  rectified  oil  is  also  obtainable, 
which  may  be  colorless  or  of  light-bluish- 
green  hue,  but  with  age  is  apt  to  turn 
yellow.  With  an  equal  volume  of  alcohol 
cajuput-oil  affords  a  clear  solution  which 
either  has  a  slightly-acid  reaction  or  is 
neutral.  The  chief  constituent  is  held 
to  be  cajuputol,  which  is  claimed  to  be 
identical  with  eucalyptol,  though  this 
requires  verification,  therapeutically  at 
least. 

Preparations  and  Doses. — Cajuput-oil, 
1  to  10  minims. 

Essence  of  cajuput  (oil  of  cajuput,  1; 
rectified  spirit,  9),  10  to  60  minims. 

Cajuput  mixture  (Hunn's  life-drops: 
oils  of  cajuput,  anise,  cloves,  and  pepper- 


mint, of  each,  1  part;  rectified  spirit,  4 
parts),  30  to  60  minims. 

Physiological  Action. — Taken  inter- 
nally, oil  of  cajuput  causes  a  sensation 
of  warmth  in  the  stomach,  excites  the 
action  of  the  heart  and  arterial  system, 
and  subsequently  induces  copious  dia- 
phoresis. Externally,  either  alone  or 
combined  with  equal  parts  of  soap-lini- 
ment or  olive-oil,  it  is  rubefacient. 

Therapeutics.  —  This  is  a  remedy  of 
much  power  and  value,  one  too  much 
neglected  in  general  practice.  Unfort- 
unately its  therapeutic  value  is  not  un- 
derstood, and  its  chemical  relation,  real 
or  supposed,  has  done  the  drug  great 
injustice.  It  is  powerfully  stimulant, 
carminative,  stomachic,  antispasmodic, 
anthelmintic,  and  antiparasitic;  also  has 
a  slight  narcotic  and  anodyne  action. 

Gout  and  Rheumatism. — When  ap- 
plied topically,  and  also  given  internally, 
in  these  affections,  this  remedy  is  often 
of  the  greatest  service;  it  should  be 
given  by  the  mouth  in  4-  to  6-drop  doses, 
as  often  as  every  second  hour,  and  some- 


670 


CALCIUM.     PREPARATIONS.     PHYSIOLOGICAL  ACTION. 


times  every  hour  in  retrocedent  gout,  in 
which  it  is  especially  serviceable. 

Intestinal  Fluxes. — In  cholera  in- 
fantum, cholera  nostras,  Asiatic  cholera, 
and  the  lesser  intestinal  fluxes,  it  has 
been  greatly  lauded,  and,  while  it  often 
appears  of  incalculable  value,  it  is  known 
to  be  a  somewhat  uncertain  remedy. 

Nervous  Diseases. — In  hysteria  it  is 
sometimes  beneficial,  particularly  hys- 
terical dysmenorrhoea;  also  in  those 
neuralgias  that  are  of  purely  nervous 
type, — i.e.,  not  dependent  upon  a  local- 
ized inflammation. 

Febrile  Maladies. — In  low  fevers  it 
is,  perhaps,  the  best  diffusible  stimulant 
known,  and  it  deserves  far  greater  at- 
tention as  regards  this  class  of  maladies 
than  has  been  hitherto  accorded  to  it. 

External  Use. — Externally  applied, 
cajuput-oil  is  of  value  in  the  treatment 
of  a  number  of  skin  maladies.  It  is  also 
useful,  oftentimes,  in  sprains  and  con- 
tusions, etc. 

CALABAR-BEAN.    See  Phtsostigma. 

CALCIUM.— This  metal  is  not  found 

in  nature  in  its  pure  state,  but  appears 
in  the  mineral  kingdom  as  marble,  lime- 
stone, calcspar,  gypsum,  selenite,  alabas- 
ter, fluorspar,  apatite,  phosphorite,  etc.; 
in  the  animal  kingdom  as  a  phosphate 
and  carbonate.  It  is  present  in  all 
vegetables.  Calcium  is  a  light,  yellow, 
very  hard,  malleable,  and  ductile  sub- 
stance that  melts  at  red  heat,  tarnishes 
in  air,  and  decomposes  water.  It  is 
rapidly  acted  on  by  dilute  acids,  and 
when  heated  burns  with  a  brilliant, 
white  light.  In  medicine  it  appears  only 
in  the  form  of  salts,  and  the  physio- 
logical action  is  modified  by  the  indi- 
vidual acid  constituent. 

Preparations  and  Doses.  —  Calcium 
bromide,  10  to  60  grains.    See  Bromine. 


Calcium  benzoate,  5  to  10  grains.  See 
Benzoic  Acid. 

Calcium  carbonate  (precipitated),  5  to 
40  grains. 

Calcium  chloride,  5  to  15  grains. 

Calcium  hippurate,  1  to  5  grains. 

Calcium  hypophosphite,  3  to  6  grains. 

Calcium  iodide,  1  to  -1  grains.  See 
Iodine. 

Calcium  lactate,  1  to  5  grains. 

Calcium  phosphate  (precipitated),  10 
to  30  grains.     See  Phosphorus. 

Calcium  sulphate  (gypsum).  Used  in 
the  preparation  of  plaster  of  Paris. 

Calcium  sulphide,  ^/n,  to  3  grains. 
Calcium  sulphocarbolate,  2  to  5  grains. 

Calcium  salicylate,  2  to  8  grains.  See 
Salicylic  Acid. 

Calcium  hypophosphite,  syrup,  1  to  4 
drachms. 

Calcium  iodide,  syrup,  15  to  30 
minims. 

Calcium  lactophosphate,  syrup,  2  to  4 
drachms. 

Lime-water,  1  to  4  ounces. 

Lime-water,  chlorinated,  30  to  60 
minims. 

Physiological  Action. — Lime  neutral- 
izes any  excess  of  acid  in  the  stomach 
and  intestines.  It  is  but  slowly  absorbed 
and  passes  into  the  blood  only  in  small 
quantities,  although  sufficient  is  taken 
up  to  promote  nutritional  changes.  It 
also  exerts  a  digitalic  action  on  the  heart : 
when  the  proportion  of  lime  present  is 
deficient,  the  contractions  are  weak;  but 
when  the  quantity  is  increased  they  be- 
come powerful.  It  is  eliminated  by  the 
intestines,  and  to  some  extent  by  the 
kidneys,  inasmuch  as  the  urine  becomes 
alkaline  under  its  administration. 

Pure  precipitated  carbonate  of  cal- 
cium appears  to  be  medicinally  of  less 
value  than  the  impure  form,  which  ob- 
tains the  names  of  "precipitated"  and 
"prepared    chalk";     both    are    neutral 


CALCIUM.     THERAPEUTICS. 


671 


salts  and  antacids,  but  the  latter  is  more 
astringent. 

Calcium  chloride  is  stimulant,  astrin- 
gent, alterative,  resolvent,  and  antisep- 
tic. Calcium  sulphide  acts  very  much 
like  the  chloride,  but  is  more  powerful. 
The  effects  of  both  depend  upon  their 
power  to  readily  and  quickly  part  with 
their  gaseous  constituents,  viz.:  chlorine 
and  sulphuretted  hydrogen,  respectively. 
The  former  is  more  powerfully  irritant 
and  cathartic. 

Lime-water  is  chiefly  antacid,  but  at 
times  appears  to  act  as  a  sedative  to  the 
gastric  viscus.  It,  as  well  as  certain  of 
the  lime  salts,  not  infrequently  gives 
rise  to  disturbance  of  digestion  and  loss 
of  appetite;  vomiting  has  been  observed 
to  follow  its  employment.  There  may 
be  an  increase  in  the  amount  of  urinary 
secretion,  but  the  stools  are  usually  re- 
tarded, though  sometimes  diarrhosa  is  a 
result. 

Calcium  peroxide  forms  a  yellow  alka- 
line powder  slightly  soluble  in  water. 
It  possesses  a  decidedly  good  action  in 
acid  dyspepsia  and  summer  diarrhoea 
occurring  in  children.  It  acts  as  a 
powerful  antiseptic  because  of  the  nas- 
cent oxygen  liberated  in  the  intestines. 
Daily  dose  ranges  from  3  to  10  grains, 
according  to  the  age  of  the  child;  best 
given  in  milk.  It  is  advisable  to  dis- 
pense the  preparation  in  parchment 
papers  preserved  in  well-closed  glass- 
stoppered  bottles,  to  prevent  decomposi- 
tion. I.  Eeszkowski  (Merck's  Bericht, 
1900). 

Therapeutics.  —  Diarrhceas.  — -  Pre- 
cipitated chalk  is  chiefly  employed  for 
its  neutralizing  effect  upon  the  acid 
secretions  of  the  prima  vice;  hence 
finds  place  among  the  remedies  recom- 
mended for  the  diarrhoeas  of  infancy  and 
childhood;  it  is  also  astringent,  and 
usually  prescribed  in  conjunction  with 
opium.  It  is  not,  however,  the  valuable 
remedy  claimed  by  earlier  writers,  and 


its  place,  to  considerable  degree,  has 
been  most  advantageously  usurped  by 
bismuth  subcarbonate  and  cerium  oxa- 
late; further,  the  more  modern  treat- 
ment of  intestinal  fluxes  is  directed 
toward  removal  of  the  cause,  rather 
than,  as  formerly,  combating  a  mere 
symptom. 

Calcium  chloride — not  calx  chlorata — 
has  on  several  occasions  been  relegated 
to  the  list  of  obsolete  remedies,  but  as 
often  has  been  again  brought  forward. 
There  is  very  little  difference  in  ther- 
apeutic applicability  from  that  of  calcic 
sulphide,  except  in  degree  of  activity  and 
size  of  dose;  therefore  the  remarks  re- 
garding one  may  be  safely  considered  as 
equally  true  of  the  other. 

As  Alteratives  and  Eesolvents. — - 
Both  are  applicable  to  a  number  of  mala- 
dies, chiefly  those  of  a  strumous,  septic, 
or  pseudoseptic  character;  they  have 
likewise  been  employed  to  some  extent 
in  the  different  forms  of  tuberculosis.  It 
is  freely  soluble  in  water. 

Skin  Disorders.  —  Chloride  of  cal- 
cium will  often  abort  furuncles  and  pro- 
duce a  salutary  influence  upon  all  stru- 
mous cutaneous  affections:  acne,  lupus, 
etc.  It  has  recently  been  recommended 
as  a  depilatory. 

In  many  instances  it  will  abort  fu- 
runcles, but  the  most  marked  effect  of 
calcium  chloride  is  in  acne.  All  stru- 
mous cutaneous  affections,  especially 
lupus,  are  often  benefited  by  it.  The 
caries  and  necrosis  of  the  same  diathesis, 
rickets,  indurated  glands,  and  tabes 
mesenterica  are  also  conditions  in  which 
it  may  be  employed  with  some  expecta- 
tion of  benefit.  Ovarian  and  uterine 
tumors  are  reported  to  have  decreased 
in  size  under  long-continued  use  of  the 
drug.  It  is  also  a  powerful  irritant  and 
cathartic. 

In  all  itching  skin  diseases  calcium 
chloride  may  be  given  after  meals. 
There  are  no  absolute  failures,  but  it 
remains  to  be  determined  in  what  class 


672 


CALCIUM. 


CAMPHOR. 


of  cases  it  is  most  useful.    Saville  (Brit. 
Med.  Jour.,  vol.  i,  '97). 

Calcivun  sulphide  recommended  as  a 
depilatory.  It  is  perfectly  harmless  to 
the  skin  and  does  not  irritate  abraded 
surfaces.  It  can  be  made  by  heating  a 
granulated  mixture  of  plaster  of  Paris 
(calcium  sulphate)  with  granulated 
wood-charcoal  (to  take  otf  the  oxygen). 
A  high  temperature  is  necessary,  and 
it  is  best  obtained  by  means  of  gas.  A 
muffler  is  used — i.e.,  set  in  cinders  or 
bone-ash — and  the  mixture  is  heated  to 
redness.  The  dry,  rose-colored  or  whit- 
ish product  is  applied  to  the  skin  in  a 
wet  condition,  or  it  may  be  put  on  dry 
ana  then  wetted.  A.  W.  Brayton  (Jour. 
Amer.  Med.  Assoc,  Apr.  16,  '98). 

Pneumonia. — In  the  past  the  remedy 
has  been  much  lauded  in  pneumonia, 
and  lately  it  has  again  been  recom- 
mended in  this  malady. 

In  lobar  pneumonia  calcium  chloride 
reduces  temperature  and  keeps  it  within 
safe  or  normal  limits  in  spite  of  the  con- 
tinuance of  physical  signs.  Moreover, 
there  is  a  tendency  for  the  morbid  proc- 
ess to  be  arrested  at  whatever  stage  the 
drug  is  given  in  efficient  doses,  whereby 
the  course  of  the  disease  is  shortened  or 
rendered  milder.  Also  there  is  singular 
freedom  from  all  anxiety,  distress,  and 
danger:  a  freedom  not  usually  asso- 
ciated with  continuous  high  tempera- 
ture. Crombie  (Practitioner,  London, 
'96;  Med.  Age,  Mar.  10,  '96). 

HEMORRHAGE.  —  On  the  plea  that 
chloride  of  calcium  was  capable  of  in- 
creasing the  coagulability  of  the  blood 
Wright,  Freudenthal,  Perry,  and  others 
have  tried  this  preparation  in  the  bleed- 
ing of  haemophilia.  It  is  to  be  given  in 
2-grain  doses  every  four  hours. 

Acting  on  Fi-eund's  theory  that  co- 
agulation of  the  blood  is  directly  pro- 
portionate to  the  excess  of  calcium 
phosphates,  these  salts  were  employed 
in  serious  heemorrhages ;  15  Vs  grains 
were  given  every  2  hoiu^s  in  water  until 
2  or  2V2  drachms  of  the  hypophosphite 
of  calcium  was  administered.  Metror- 
rhagias,   intestinal     hsemorrhages     (ty- 


phoid),    gastrorrhagia,     and     epistaxis 
were  very  rapidly  checked.     For  check- 
ing most  haemorrhages  this  may  be  re- 
lied   upon.      M.    Silvestri     (Bull.    MSd., 
Feb.  6,  '98). 
Influenza. — In    doses    of    1    grain 
daily  calcium  sulphide  has,  on  various 
occasions,  shown  a  very  favorable  action 
over  influenza,  and  not  infrequently  the 
attack  is  aborted. 

Calcium  eosolate  is  valuable  in  the 
treatment  of  diabetes  insipidus,  diabetes 
mellitus,  and  chronic  ulcerative  phthisis. 
Dose  is  from  4  to  10  grains  three  or  four 
times  a  day.  It  is  soluble  in  from  8  to 
10  parts  of  cold  and  in  7  parts  of  hot 
water.  H.  Stern  (Jour.  Amer.  Med. 
Assoc,  xxxiv,  p.  467,  1900). 

CALCULI,  BILIARY.  See  Chole- 
lithiasis. 

CALCULI,  SALIVARY.  See  Sali- 
vary Glands. 

CALCULI,  VESICAL.  See  Urinary 
System,  Surgical  Diseases  of. 

CALOMEL.    See  Mercury. 

CAMP  FEVER.    See  Typhus  Fever. 

CAMPHOR. — This  is  a  peculiar,  con- 
crete, volatile  substance  obtained  by 
sublimation  from  the  Cinnamomum  cam- 
plwra :  a  native  of  China,  Japan,  and 
some  of  the  isles  of  the  East  Indian 
Archipelago.  Camphor  is  also  found  in 
white  crystals  in  the  fragments  in  the 
wood  of  Drrjopalanops  campJiora.  It 
appears  in  small  quantities  in  various 
other  plants,  and  Tenasserim  camphor, 
which  is  of  fair  quality,  is  a  yield  of  the 
leaves  and  stalks  of  Blumea  grandis  (or 
campher).  It  is  sparingly  soluble  in 
water,  but  freely  so  in  alcohol,  ether, 
chloroform,  and  fluid  and  volatile  oils; 
vrith  chloral  or  carbolic  acid  it  forms  a 
clear  liquid.  As  found  in  the  shops,  it 
is  a  white,  translucent  gum  of  tough. 


CAMPHOR.    PREPARATIONS.    PHYSIOLOGICAL  ACTION. 


673 


almost  crystalline  structure,  possessed  of 
a  pungent,  bitter  taste  that  leaves  in  the 
mouth  a  feeling  of  coolness.  Camphor 
is  incompatible  with  acids,  iodine,  etc. 

Camphoric  acid  is  formed  by  oxidation 
of  camphor  with  nitric  acid,  and  appears 
as  a  white,  microcrystalline  powder,  very 
slightly  soluble  in  water,  with  a  faint 
aromatic  odor  and  slight,  saline,  cam- 
phor taste. 
-  Camphor-chloral  is  merely  a  mixture 
of  equal  parts  of  gum-camphor  and 
chloral-hydrate  whereby  is  produced  a 
colorless,  syrupy  liquid,  which  is  soluble 
in  alcohol,  ether,  chloroform,  benzin, 
glycerin,  fixed  oils,  and  aqueous  solutions 
of  chloral;  but  when  added  to  water  it  is 
decomposed,  the  chloral  passing  into 
solution,  while  the  camphor  is  precipi- 
tated. 

Camphor-menthol  is  made  by  rubbing 
together  equal  parts  of  menthol  and 
camphor  whereby  a  clear  liquid  is 
formed.  Camphor-thymol  is  made  in 
the  same  way,  precisely,  as  camphor- 
menthol.  Other  compounds  are  formed 
in  like  manner  of  the  two  foregoing  by 
combining  camphor  and  salol  and  cam- 
phor and  resorcin.  Camphor-oil  is  a 
crude  residual  product  resulting  from 
the  distillation  of  camphor-gum. 

Camphor-monobromate,  or  monobro- 
mated camphor,  is  had  by  heating  cam- 
phor-gum and  bromine,  previously  dis- 
solved together  in  benzin,  and  then  crys- 
tallizing from  hot  alcohol;  it  is  almost 
insoluble  in  water,  but  readily  dissolves 
in  alcohol,  chloroform,  ether,  and  fixed 
oils. 

Camphor-salic3date  may  be  prepared 
by  heating  together  carefully  84  parts  of 
camphor  and  6.5  parts  of  salicylic  acid, 
until  a  liquid,  homogeneous  solution  is 
formed,  which  becomes  a  crystalline 
mass  on  cooling;  this  again  becomes 
unctuous  when  compressed,  and  liquefies 


when  rubbed  on  the  skin.  It  may  be 
obtained  in  definite  crystals  from  a 
benzin  solution.  It  is  slightly  soluble  in 
water  and  glycerin,  about  1  to  20  in  fats 
or  oils,  and  is  decomposed  by  hot  alka- 
line solutions.  By  boiling  with  water  it 
hydrates  into  an  oily  liquid. 

Carbolized  camphor,  or  phenol-cam- 
phor, is  had  by  adding  2  parts  of  cam- 
phor-gum to  1  part  of  carbolic  acid,  and 
is  a  colorless,  oily  liquid,  soluble  in  fixed 
oils,  alcohol,  and  ether,  but  nearly  in- 
soluble in  water  and  glycerin. 

Preparations  and  Doses.  — ■  Camphor- 
chloral,  2  to  20  minims. 

Camphor,  carbolized,  external  use 
only.    See  Phenic  Acid. 

Camphor-gum,  2  to  20  grains. 

Camphor-liniment  (camphor,  1;  olive-, 
peanut-,  or  cotton-seed  oil,  4). 

Camphor  liniment,  compound  (cam- 
phor, 20  drachms;  lavender-oil,  1 
drachm;  strong  ammonia-water,  5 
ounces;  rectified  spirit,  15  ounces). 

Camphor-menthol,  1  to  5  grains. 

Camphor,  monobromated  (bromide  of 
camphor),  1  to  12  grains. 

Camphor-oil  (crude),  external  use 
only. 

Camphor,  salicylated  (salicylate  of 
camphor),  1  to  5  grains. 

Camphor  spirit  (tincture  of  camphor), 
5  to  30  minims. 

Camphor-thymol,  1  to  5  grains. 

Camphorated  oil  (camphor,  1;  sweet 
almond  oil,  9),  5  to  60  minims. 

Camphorated  tincture  of  opium  (pare- 
goric), 30  minims  to  4  drachms.  See 
Opium. 

Camphoric  acid,  5  to  30  grains. 

Physiological  Action.  —  Externally 
camphor  is  somewhat  rubefacient, 
readily  irritating  the  skin.  Given  in- 
ternally, it  acts  chiefly  upon  the  brain, 
cord,  and  circulatory  apparatus.  In 
small  doses  it  increases  the  action  of  the 


674 


CAMPHOR.     THERAPEUTICS. 


heart  and  arteries:   the  pulse  is  rendered 
softer    and    fuller.      It    exhilarates    the 
spirits,  and  excites  warmth  of  body,  pro- 
moting diaphoresis;  but  these  effects  are 
transitory  and  fleeting  and  apt  to  be  fol- 
lowed by  depression.     In  larger  doses 
it  is  sedative,  antispasmodic,  somewhat 
hypnotic  and  analgesic,  and  sometimes 
markedly  anaphrodisiac.     In  poisonous 
doses    it   irritates    the    gastro-intestinal 
mucous     membrane;      induces     nausea, 
vomiting,  vertigo,  delirium,  maniacal  ex- 
citement, and  convulsions  of  an  epilepti- 
form character;   cardiac  prostration  and 
muscular  weakness  are  often  very  pro- 
nounced.    It  is  antidoted  by  emetics, 
rapid-acting  cathartics,  and  stimulants. 
Case  of  a  lady,  78  years  of  age,  who 
took  an  unknown  quantity  of  spirit  of 
camphor.     About  an  hour   after  taking 
it  she  became  comatose,  and  finally  ap- 
peared  to    be    dead.      Consciousness    re- 
turned after  a  considerable  interval,  and 
it   was   found   on  examination  that  her 
right  hand  and   right  side   of  her   face 
were  paralyzed.     In  four  weeks  she  was 
able  to  walk  about  the  room  with  assist- 
ance.    Some  five  months  later  she  could 
pick  up  a  pin  from  the  floor  with  the  af- 
fiioted  hand,  and  there  was  no  perceptible 
trace  of  the  facial  paralysis.     Treatment 
consisted  of  tonic  doses  of  nux  vomica 
and  gentle  massage  to  the  affected  parts. 
T.  B.  Greenley  (Amer.  Pract.  and  News, 
July  15,  1900). 
Camphor-chloral  combines  the  virtues 
of  the  two  drugs  from  which  it  is  de- 
rived;  it  is  sedative,  hypnotic,  and  nar- 
cotic. 

Monobromated  camphor  is  moderately 
stimulating  and  diaphoretic,  but  is 
scarcely  a  succedaneum  for  other  bro- 
mides; it  decidedly  lowers  temperature; 
is  anodyne,  antispasmodic,  and  narcotic; 
in  large  doses,  sedative.  In  very  large 
doses  it  depresses  and  weakens  the 
heart's  action. 

Salieylated  camphor  acts  very  much 
like  monobromated  camphor;   it  is  less 


antiseptic,  however,  and  more  analgesic. 
Very  large  doses  of  either  this  or  the 
monobromated  form  induce  muscular 
trembling  and  clonic  convulsions. 

Camphoric  acid  is  antiseptic,  some- 
what diuretic  and  astringent,  and  anti- 
sudorific.  It  is  eliminated  chiefly  by 
the  urine,  which  it  renders  clear  and 
acid. 

The  physiological  action  of  the  other 
preparations  is  not  sufficiently  differ- 
ential to  require  mention. 

Therapeutics. — As  an  Antigalacta- 
GOGUE. — The  external  uses  of  camphor 
are  many  and  varied,  and  exemplified 
in  almost  every  household.  The  tincture 
applied  to  the  breasts  of  the  nursing 
woman  proves  markedly  antigalacta- 
gogic:  an  effect  which  is  heightened  and 
materially  aided  if  the  same  is  also  ad- 
ministered at  the  time  by  the  mouth. 

The  most  desirable  method  is  to  di- 
minish the  patient's  drink,  administer 
purgatives,  and  place  over  the  breasts 
an  ointment  or  liniment  of  camphor;  to 
also  give  camphor  internally  in  doses  of 
1  or  2  grains,  once,  twice,  or  thrice  daily. 
When  both  tlie  external  and  internal 
treatment  bj'  camphor  are  resorted  to, 
the  decrease  in  the  secretion  of  milk  is 
quite  remarkable.  Herrgott  (Indfip. 
Med.;    Med.  Age,  '97). 

Febeile  and  Infectious  Diseases. 
• — In  low  forms  of  pyrexia  camphor  is 
often  a  remedy  of  great  value.  A  solu- 
tion in  acetic  acid  was  at  one  time  held 
to  be  an  almost  specific  in  common  con- 
tinued, pestilential,  exanthematic,  and 
puerperal  fevers;  and  even  yet  it  is  ad- 
mitted to  be  of  great  value,  but  difficult 
to  administer.  It  is,  however,  contra- 
indicated  where  there  is  either  a  flesh- 
red  tongue  or  tenderness  of  the  abdomen 
with  diarrhoea.  Latterly,  more  espe- 
cially in  Europe,  the  hypodermic  admin- 
istration of  camphor  dissolved  in  sweet 
almond  oil  is  lauded  in  these  maladies; 


CAMPHOR.     THERAPEUTICS. 


675 


also  in  asthenic  and  advanced  stages  of 
acute  inflammations  when  the  vital 
povcers  are  greatly  exhausted,  and  in 
delirium  accompanied  by  depressed 
nerve-energy;  but  it  sometimes  requires 
to  be  reinforced,  so  to  speak,  by  other 
stimulants  and  sedatives.  In  the  main, 
however,  the  administration  hypodermic- 
ally  has  little  to  commend  it  over  in- 
gestion by  the  stomach. 

In  infectious  diseases,  the  exanthe- 
mata, pleuro-pneumonia  with  meningeal 
symptoms,  in  infectious  endocarditis, 
etc.,  more  especially  if  the  patient  is  in 
a  condition  of  collapse,  15  to  45  minims 
of  a  10-per-cent.  solution  of  camphor- 
ated oil  afford  prompt  relief,  employed 
subcutaneously.  Even  so  much  as  15 
grains  of  camphor  daily,  far  from  ag- 
gravating, ameliorated  cerebral  symp- 
toms. From  7  to  15  grains  produce 
remarkable  restorative  effects.  Schill- 
ing (La  Med.  Moderne,  Nov.  30,  '95). 

In  influenza,  pneumonia,  typhoid, 
broncho-pneumonia,  etc.,  camphorated 
oil  yields  good  results,  but  should  be 
administered  before  the  patient  is  too 
weak;  it  produces  an  increase  of  ar- 
terial pressure,  free  expectoration,  and 
a  feeling  of  physical  well-being.  If 
given  by  the  mouth  its  taste  may  be 
disguised  by  essence  of  pepermint.  It 
appears  to  be  contra-indicated  where 
there  is  great  cerebral  excitement. 
Tuassia  (Gaz.  deg.  Ospitali,  Mar.  8,  '92; 
Brit.  Med.  Jour.,  Mar.  26,  '92). 

Camphoric  acid  in  ^/^-drachm  doses 
one  hour  before  bed-time,  with  a  glass 
of  milk  or  water,  is  of  value  for  night- 
sweats.  The  medicine  is  best  given  dry 
on  the  tongue,  and  then  washed  down 
with  water  or  milk.  Coston  (Ther.  Gaz., 
Mar.  15,  '99). 

In  small-pox  and  other  exanthemata, 
when  the  eruption  has  receded,  camphor 
in  small  and  oft-repeated  doses  fre- 
quently causes  restoration;  but  if  there 
is  inflammation  of  important  viscera  the 
drug  is  contra-indicated. 

Mental  and  Nervous  Diseases.- — 
In  the  past,  camphor  obtained  a  fore- 


most place  in  the  treatment  of  insanity, 
and  there  is  every  reason  to  believe  it 
is  now  too  much  neglected.  When  the 
patient  is  of  nervous  temperament,  or 
there  is  deficient  nerve  or  vital  power; 
when  the  head  is  cool  and  the  mental 
affection  independent  of  vascular  full- 
ness or  action;  when  there  is  much  rest- 
lessness, low,  weak  pulse,  or  cold,  clammy 
skin;  or  when  exhaustion  follows  the 
foregoing  or  is  superimposed  on  pre- 
vious excitement,  the  drug  may  usually 
be  given  to  marked  advantage;  but  it  is 
not  to  be  advised  when  there  is  cerebral 
excitement  with  a  hot  skin,  full  pulse, 
and  wild  countenance.  In  puerperal  in- 
sanity, especially,  it  is  frequently  of  the 
most  service;  but  here,  as  in  all  other 
conditions  of  mental  alienation,  it  re- 
quires to  be  employed  with  discrimina- 
tion. 

Diseases  of  the  Heart. — In  heart- 
maladies  camphor  is  occasionally  very 
beneficial;  it  will  frequently  quiet 
tumultuous  palpitations  and  remove  the 
dyspnoea  which  often  attends  hyper- 
trophy with  dilatation. 

Camphor  is  to  be  recommended  hypo- 
dermically  in  heart-failure,  preferably 
employing  camphorated  oil.  In  a  case 
in  which  the  patient  had  a  number  of 
times  been  absolutely  pulseless  and  ap- 
parently lifeless  its  use  was  followed  by 
the  most  gratifying  results.  West 
(Phila.  Polyclinic,  Oct.  16,  '97). 

Intestinal  Fluxes.  —  Camphor, 
either  in  powder  or  tincture,  is  an 
excellent  and  popular  remedy  for  the 
diarrhoeas  of  summer  and  autumn, 
which  so  often  assume  a  choleraic  form. 
When  the  body  is  cold  as  ice,  there  is 
great  prostration,  the  voice  squeaky  and 
husky,  and  the  upper  lip  retruded,  the 
effect  of  the  remedy  is  said  to  be  often 
marvelous. 

It  is  essential  to  use  the  strong  solu- 
tion or  essence    (spirit)    of  camphor,  of 


676 


CAMPHOR.    THERAPEUTICS. 


which  3  minims  should  be  given  on  a 
cube  of  sugar  or  on  a  crumb  of  bread 
every  five  minutes.  After  one  or  two 
doses  the  diarrhoea  ceases,  the  pulse  be- 
comes stronger,  color  returns  to  the  face, 
and  the  patient  is  on  the  high  road  to 
recovery.  The  tincture  is  almost  equally 
useful  in  the  initial  rigor  of  acute  spe- 
cific diseases  and  in  severe  chill.  Mur- 
rell  ("Manual  of  Mat.  Med.  and  Ther.," 
'96). 

Few,  if  any,  remedies  are  comparable 
to  camphor  in  summer  diarrhoea  and 
cholera.  Its  benign  influence  in  the 
latter  disease  is  most  conspicuous,  for  it 
generally  checks  the  vomiting  and  diar- 
rhoea immediately,  prevents  cramp,  and 
restores  warmth  to  the  extremities.  It 
must  be  given  at  the  very  commence- 
ment, and  repeated  frequently,  other- 
wise it  is  useless.  Four  to  6  drops  of 
the  strongest  tincture  should  be  given 
every  ten  minutes  until  the  symptoms 
abate,  and  then  hourly.  Ringer  and 
Sainsbury    ("Hand-book  of  Ther.,"  '97). 

Therapeutics  of  Various  Preparations 
of  Camplior. — Monobromated  and  salic- 
ylated  camphor  have  been  employed  in 
diarrhosaj    dysentery,    epilepsy,    chorea, 
hysteria,  asthma,  neuralgia,  etc.    Not  one 
is  as  marked  in  stimulant  action  as  the 
camphor-gum  or  tincture,  but  the  mono- 
bromate  is  an  hypnotic  of  considerable 
power  and  an  invaluable  antispasmodic. 
There  is  no  better   remedy  than   the 
monobromate   in    the   treatment    of   in- 
fantile diarrhoea  and  the  convulsions  of 
dentition.    Curryer  (Chicago  Med.  Times, 
July,  '91). 

Marked  success  is  had  in  relieving 
chordee  by  using  suppositories  of  cam- 
phor-monobromate.  Vanderbeck  (Pacific 
Med.  Jour.,  June,  '91). 

Salicylated  camphor  is  said  to  be  of 
marked  utility  when  applied  in  the  form 
of  ointment  to  lupus  and  rodent  ulcer. 
It  is  also  employed  in  diarrhea,  but  is 
in  no  way  superior  to  the  monobromate. 

Camphor-chloral  has  found  its  chief 
employment  in  mania,  delirium  tremens, 
etc.     It  is  said  that  the  sedative  effect 


is  far  in  excess  of  that  of  either  of  its 
constituents.  Prolonged  narcotism,  last- 
ing several  days,  had  followed  excessive 
use  of  the  drug.  Applied  topically  it  is 
often  efEective  in  relieving  neuralgic 
pains. 

Phenicated  camphor  was  originally 
introduced  as  an  ansesthetic  and  as  an 
antiseptic  dressing,  but  seems  to  have 
found  favor  with  some  in  the  manage- 
ment of  skin  maladies. 

It  is  a  useful  application  in  toothache 
due  to   an   exposed  and   inflamed   pulp. 
A    valuable    deodorant    to    correct    the 
foetor  arising  from  syphilitic  ulcerations, 
malignant    growths,     gangrene     of    the 
lungs,  bronchorrhoea,  and  pneumothorax. 
It  reduces  the  discharge  and  relieves  the 
pain   in   acute   otitis   media;     a   10- per- 
cent,   solution    in    glycerin    should    be 
used.     Also   available   in   otorrhoea  and 
in    acute    perforation    of    the    tj'mpanic 
membrane  in   1-  or  2-per-cent.  solution. 
Is  an  efficient  antiseptic  in  foul  and  in- 
dolent ulcers,  and  may  be  used  in  the 
form  of  a  lotion:    8  to  15  grains  to  the 
ounce.       Butler     ("Text-book     of     Mat. 
Med.,  Ther.,  and  Phar.,"  '96). 
Thymol-camphor  has  been  suggested 
as  a  preparation  that  would  be  valuable 
in  dermatological  practice,  but  has  re- 
ceived, apparently,  but  little  attention. 
Used   in  pruritus   of   scrotum   and   in 
pediculosis  pubis  with  apparently  good 
results.     Applied  to  the  normal  healthy 
skin,  it  does  not  cause  any  irritation  or 
redness.      Schaefer     (Boston    Med.    and 
Surg.  Jour.,  '90). 
Menthol-camphor  is  very  like  the  fore- 
going.    It   has  been  exploited  for  the 
treatment  of  catarrhal  maladies,  includ- 
ing "hay"  asthma  or  fever,  acute  laryn- 
gitis, etc. 

In  hypertrophic  nasal  catarrh,  with 
excessive  and  disordered  secretion,  a  2.5- 
per-eent.  solution  of  the  drug  has  given 
excellent  results.  It  was  equally  eflfect- 
ive  in  chronic  hypertrophic  rhinitis,  as 
well  as  in  eczematoug  and  herpetic  erup- 
tions. Bishop  (Kansas  City  Med.  Index, 
Mar.,  '92). 


CANNABIS  INDICA. 


677 


Camphoric  acid  is  one  of  many  reme- 
dies introduced  with  a  view  to  treating 
tuberculosis  by  destroying  bacilli,  but  it 
has  failed  to  fulfill  the  role  laid  down  for 
it.  Latterly  it  has  been  employed  in  a 
host  of  nervous  diseases,  and  as  a  remedy 
against  night-sweats,  cystitis,  etc.,  and 
it  has  appeared  to  be  of  some  value  in 
the  management  of  epilepsy. 

Ordinary  angina  and  catarrhal  pharyn- 
gitis were  much  improved  by  gargles 
of  14-  to  1-per-cent.  solution;  applied  by 
brush  or  as  a  spray,  in  fourteen  eases 
of  laryngitis  it  gave  excellent  results. 
Proved  gratifying  in  cystitis,  but  its 
inhalation  in  lung  diseases  was  without 
noticeable  effect.  Hurtleib  (Wiener 
med.  Presse,  Feb.  23,  '90). 

It  is  a  powerful  innocuous  antiseptic, 
especially    in    gonorrhoea,    cystitis,    and 
diphtheria.    A  dose  of  1/2  drachm  in  one 
case  induced  gastric  irritation  and  vomit- 
ing.    Warman   (Gaz.  lekar..  No.  36,  '89; 
Prov.  Med.  Jour.,  Jan.,  '90). 
Camphor-oil  has  never  found  a  definite 
place  in  medicine   except  domestically, 
and  then  for  external  use  only.   Latterly, 
however,  a  few  spasmodic  attempts  have 
been  made  to  give  it  place,  and  sug- 
gestions have  been  thrown  out  regarding 
its  internal  adminstration.    It  is  a  crude 
product   of  uncertain   strength,   and   it 
can  serve  no  purpose  that  cannot  be 
better  filled  by  a  solution  of  camphor- 
gum  in  oil  of  sweet  almonds. 

Oxycamphor  is  a  colorless,  crystalline 
powder,  soluble  up  to  2  per  cent,  in  cold 
water.  It  may  be  administered  in  gela- 
tin capsules.  The  daily  amount  may  be 
as  much  as  30  grains.  It  is  of  value  for 
the  relief  of  dyspnoea  due  to  pulmonary, 
cardiac,  or  renal  disorders.  Alfred 
Ehrlich  (Centralb.  f.  d.  gesammte  Ther., 
H.  1,  S.  1, '99). 

CANCER.    See  Tumors. 

CANCRUM  ORIS.  See  Mottth,  Gak- 
GREXous  Stomatitis. 

CANNABIS  INDICA  SEU  SATIVA.— 
Indian,  European,  and  American  hemp 


are  one  and  the  same,  except  as  modified 
by  locality,  climate,  soil,  and  culture. 
The  plant  attains  its  highest  medicinal 
virtues  when  grown  in  the  tropics  or 
subtropics,  inasmuch  as  here  it  develops 
a  larger  amount  of  resin  (churrus).  The 
dried  flowering  tops  of  the  female  plant 
are  the  parts  employed  medicinally,  and 
it  is  essential  to  medicinal  virtue  that 
the  resin  be  not  removed;  these  tops 
in  their  crude  condition  are  known  as 
gunjah.  The  Arabian  hasheesh,  Hindoo 
bhang,  and  Mohammedan  majoon  are 
practically  identical,  being  aromatic  con- 
fections into  which  not  only  cannabis 
Indica,  but  the  powdered  seeds  of  stra- 
monium, enter.  Hasheesh  is  not,  as  has 
been  stated,  "the  broken  stalks  of  the 
hemp  made  up  into  fruits." 

The  chemistry  of  hemp  is  not  well  un- 
derstood. The  resin,  or  churrus,  accord- 
ing to  Egasse,  is  the  active  principle, 
and  has  received  the  name  of  "canna- 
bin";  but  Helbing  gives  this  title  to  a 
supposed  alkaloid  of  syrup-like  con- 
sistency and  brownish-  or  greenish-  black 
hue,  scarcely  at  all  soluble  in  water,  but 
freely  so  in  ether  and  alcohol.  Jahns 
insists  that  the  only  alkaloid  is  choline, 
and  all  other  supposed  principles  are 
impure  choline.  Inasmuch  as  this  same 
name  obtains  to  a  base  found  in  plants 
and  animals,  formerly  known  as  "sinha- 
line"  and  "titineurine,"  and  described 
chemically  as  oxy-ethyl-trimethyl-am- 
monium,  its  applicability  is  questionable. 

Cannabindon  is  another  derivative  of 
hemp,  and  appears  in  the  form  of  a  dark, 
cherry-red  syrup. 

The  eannabine  alkaloid  of  Merck  is 
had  in  fine  needles,  but  its  relations  to 
the  entire  drug  are  not  yet  fully  deter- 
mined; it  is  not  even  known  that  it  is 
a  true  alkaloid.  So,  too,  there  is  found 
in  market  another  "alkaloid"  bearing 
the  same  title,  and  which  is  a  translu- 


678 


CANNABIS  INDICA.    PREPARATIONS.    PHYSIOLOGICAL  ACTION. 


cent,  brown,  syrupy  liquid,  with  the 
hemp  odor. 

Cannabine  tannate  is  a  yellowish- 
brown  powder  with  a  tannin-like  taste, 
not  unpleasant  smell,  insoluble  in  pure 
water  and  ether,  soluble  in  alcohol,  and 
freely  so  in  water  made  alkaline;  it  is 
said  to  be  free  from  the  two  acrid  and 
volatile  oils  peculiar  to  hemp  and  which 
are  generally  held  to  be  rapidly-acting 
irritant  poisons.  Cannabinine  is  a  yel- 
lowish-brown, syrupy  liquid  with  an 
odor  very  similar  to  that  of  nicotine. 
Cannabindon  is  a  purified  churrus  of 
dark-brown  color,  the  consistency  of 
treacle,  and  a  most  disagreeable  taste; 
it  is  insoluble  in  water. 

In  the  Orient  churrus  is  smoked,  and 
also  manufactured  into  an  intoxicating 
drink.  A  butter  is  also  employed  in  the 
Hindoostani  peninsula. 

Preparations  and  Doses. — As  a  whole, 
cannabis  is  one  of  the  most  valuable  of 
drugs,  but  is  sadly  handicapped  by  the 
uncertainty  that  attends  all  pharma- 
copoeial  preparations.  Attempts  to  pre- 
pare by  methods  of  assay  have  not  been 
attended  with  any  marked  degree  of  suc- 
cess, owing  to  the  fact  that  such  have 
necessarily  been  based  on  the  amount  of 
the  extractive.  Too  little  is  known  re- 
garding the  so-called  active  principles 
to  place  any  reliance  on  them  as  guide^s; 
consequently  the  sole  dependence  of  the 
prescriber  is  the  character  of  the  manu- 
facturer, and  the  ability  of  the  latter  to 
iudge  of  the  crude  drug  employed.  For 
such  reasons  cannabis  requires  to  be 
employed  with  judgment  and  caution. 
It  has  been  noted,  too,  that  larger  doses 
are  required  in  temperate  climes  than  in 
the  tropics  and  subtropics  to  produce  a 
definite  effect;  but  the  real  truth,  doubt- 
less, lies  in  the  fact  that  the  drug  de- 
teriorates with  age  and  by  transporta- 
tion;   perhaps  loses  some  undetermined 


volatile  constituent.  The  same  precise 
preparation  may  prove  active  to-day; 
but,  given  to  the  same  patient  under 
equally  favorable  conditions  a  few  weeks 
later,  may  prove  practically  inert.  Honi- 
berger  observed  that  a  resinous  extract 
prepared  for  him  in  Calcutta  was  very 
much  less  energetic  when  he  reached 
London. 

Cannabis  Indica  abstract,  y,  to  4 
grains. 

Cannabis  extract  (solid),  V*  fo  ^ 
grains. 

Cannabis  extract  (fl.uid),  V2  to  6 
minims. 

Cannabin  (resin),  1  to  5  grains. 

Cannabindon,  '^/„  to  1  minim. 

Cannabine  (alkaloid),  ^/j  to  4  grains. 

Cannabin  tannate,  2  to  15  grains. 

Cannabine  (liquid),  1  to  3  minims. 

Cannabinine,  V^  to  1  grain. 

Cannabis  tinctiire,  5  to  30  minims. 

Cannabis-butter,  3  to  8  grains. 

Liquor  cannabis  (Lees's),  15  to  60 
minims. 

Physiological  Action. — The  alkaloids 
appear  to  be  purely  hypnotic  in  action; 
but  all  other  preparations  exhibit,  in  a 
general  way,  the  action  of  the  crude 
drug.  Minute  doses  are  sedative  to  the 
spinal  centres,  and  even  when  frequently 
repeated  exhibit  little  to  be  remarked, 
except,  perhaps,  there  may  be  slight  con- 
traction of  the  pupils;  but  there  is, 
nevertheless,  inculcated  a  feeling  of 
comfort  and  well-being,  and  not  infre- 
quently the  drug  appears  to  steady  the 
action  of  the  heart.  Larger  doses  are 
stimulant;  they  first  induce  increased 
arterial  action,  followed  by  exhilaration, 
and,  as  the  latter  passes  off,  drowsiness 
or  stupor  succeeds,  that  may  be  almost 
cataleptic;  but  the  awakening  is  free 
from  malaise,  nausea,  headache,  or  other 
untoward  symptoms;  the  pupil  of  the 
eye  is  expanded.    The  preliminary  effect 


CANNABIS  INDICA.    POISONING.    TREATMENT.    THERAPEUTICS. 


679 


is  more  powerful  and  lasting  than  that  of 
opium,  and  the  slumber  it  induces  is 
commonly  disturbed  by  dreams  and 
spectral  illusions.  Also  the  sensory 
nerves  are  affected,  as  is  evidenced  by 
marked  numbness  and  tingling,  ushering 
in  cutaneous  ansesthesia  and  diminution 
of  the  muscular  sense.  Appetite  is  gen- 
erally stimulated,  and  marked  aphrodisia 
is  not  uncommon.  Withal  it  is  a  valu- 
able anodyne  and  antispasmodic,  its  in- 
fluence being  manifested  through  the 
brain  and  cord. 

Cannabis  Indica  likewise  exhibits  a 
marked  predilection  for  the  genito- 
urinary apparatus,  being  strongly  stimu- 
lant or  sedative  to  the  mucous  tissue 
thereof  in  accordance  with  the  mode  of 
exhibition  and  size  of  dose;  it  is  some- 
times markedly  diuretic,  and  appears  to 
be  excreted  in  part  by  the  kidneys;  but 
beyond  this  the  eliminative  process  is 
unknown.  Further,  in  atonic  conditions 
or  inertia  during  labor,  it  stimulates 
uterine  activity  and  induces  physio- 
logical contractions,  and  at  a  time  when 
ergot  and  kindred  remedies  prove  use- 
less. 

The  effects  of  cannabis  Indica  vary  ac- 
cording to  the  manner  in  which  it  is 
talcen  into  the  system.  When  smoked, 
exhilaration  is  most  manifest,  while 
when  talcen  by  the  mouth  in  small  quan- 
tities this  is  generally  not  observed. 
Where  an  immedate  effect  is  desired  the 
drug  should  be  smoked,  the  fumes  being 
drawn  through  water.  By  the  mouth, 
one  hour  to  two  hours  are  necessary  be- 
fore absorption  occurs,  but  the  effects 
are  more  lasting  than  when  it  is  inhaled. 
The  hemp  when  taken  as  an  inhalation 
may  be  placed  in  the  same  category  as 
coffee,  tea,  and  kola.  Used  by  the  mouth 
it  should  be  classified  with  the  narcotics. 
No  danger  is  to  be  apprehended  while 
the  heart  remains  strong  and  regular. 
Dixon  (Brit.  lied.  .Jour.,  Nov.  11.  '09). 

Poisoning   by    Cannabis   Indica. — In 

large  doses  the  drug  appears  toxic,  and 


yet,  strange  to  say,  in  spite  of  the  enor- 
mous quantities  (relatively)  that  have 
been  ingested  on  certain  occasions, 
either  accidentally  or  purposely,  a  case 
of  death  directly  referable  to  this  drug 
has  yet  to  be  recorded. 

In  a  case  after  cannabis  Indica  in  large 
dose  the  existence  of  muscular  contrac- 
tions was  noted,  followed  later  by  con- 
vulsive movements,  evidently  due  to  ac- 
tion of  the  drug  on  the  spinal  cord.  Aside 
from  acceleration  of  the  pulse-rate  and 
feeling  of  fullness  in  the  artery  at  the 
wrist,  there  was,  just  previous  to  the 
occurrence  of  unconsciousness,  a  sense  of 
extreme  tension  in  the  abdominal  blood- 
vessels: they  felt  distended  almost  to 
bursting.  After  some  hours  the  urine 
was  markedly  increased  in  quantity.  No 
constipation  resulted.  There  was  no  fore- 
boding nor  fear  of  impending  death. 
Robert  C.  Bieknell  (Thera.  Gazette,  No. 
1,  p.  13,  '98). 

Treatment  of  Poisoning. — Cannabis  is 
antagonized  by  caustic  alkalies,  vinegar 
and  other  acids,  strychnine,  electricity, 
antimonials,  and  blisters  to  the  nape  of 
the  neck. 

Therapeutics. — Hemp  is  soporific  or 
hypnotic,  anodyne,  antispasmodic,  nerv- 
ine stimulant,  and,  as  already  remarked, 
in  some  measure  diuretic,  aphrodisiac, 
and  oxytocic;  consequently  its  scope  of 
usefulness  is  a  most  extended  one,  par- 
ticularly in  nerve-maladies. 

Its  most  important  effects  are  to  be 
found  in  the  mental  sphere,  as,  for  in- 
stance, in  senile  insomnia  with  wander- 
ing. An  elderly  person  (perhaps  with 
brain-softening)  is  iidgety  at  night,  goes 
to  bed,  gets  up,  thinks  he  has  some 
appointment  to  keep,  that  he  must  dress 
and  go  out;  daylight  finds  him  quite 
rational  again.  Here  nothing  can  com- 
pare in  utility  to  a  moderate  dose  of 
cannabis.  In  alcoholic  subjects,  how- 
ever, it  is  uncertain  and  rarely  useful. 
In  melancholia  it  is  sometimes  service- 
able in  converting  depression  into  ex- 
altation.    In   the   occasional   night-rest- 


680 


CANNABIS  INDICA.    THERAPEUTICS. 


lessness  of  paretics,  and  the  "temper  dis- 
ease" of  Marshall  Hall,  it  has  proved 
eminently  useful.  In  neuralgia,  neuritis, 
and  migraine  it  is,  by  far,  the  most 
useful  of  drugs,  even  when  the  disease 
has  persisted  for  years;  many  victims 
of  diabolical  "sick  headache"  have  for 
years  kept  their  sufferings  in  abeyance 
by  taking  hemp  at  the  threatened  onset 
of  the  attack.  It  relieves  the  lightning 
pain  of  ataxia,  and  also  the  multiform 
miseries  of  the  gouty.  Again,  in  chronic 
spasm,  whether  epileptic  or  choreic,  it 
is  of  great  service;  also  in  the  eclampsia 
of  both  children  and  adults.  In  brain- 
tumors  or  other  maladies  in  the  course 
of  which  epileptic  seizures  occur  followed 
by  coma,  the  coma  being  followed  by 
delirium, — first  quiet,  then  violent,  the 
delirium  then  passing  into  convulsions, 
and  the  whole  gamut  being  repeated, — 
Indian  hemp  will  at  once  cut  short  such 
abnormal  activities,  even  when  all  other 
treatment  has  failed;  but  in  genuine 
epilepsy  it  is  of  little  avail.  J.  Russell 
Reynolds  (Lancet,  London,  Mar.  2,  '90; 
N.  Y.  Med.  Jour.,  June  7,  '90). 

Cannabis  Indica  employed  with  good 
effect  as  a  local  ansesthetie  to  relieve 
dental  pain.  The  tincture  is  diluted 
three  to  five  parts  with  alcohol,  and  is 
introduced  into  the  cavity  of  the  tooth 
by  means  of  a  tampon  of  cotton.  These 
tampons  are  also  placed  about  the  gum 
below  the  tooth.  If  the  alcohol  is  too 
strong  the  tincture  may  be  diluted  by 
means  of  hot  water.  Aarousin  (Jour,  de 
M6d.  de  Paris,  Oct.  30,  '98). 

Cannabis  Indica  may  be  employed  in 
the  solid  extract,  from  8  to  20  grains 
being  given.  With  a  few  exceptions, 
its  efficacy  is  limited  to  those  diseases 
directly  traceable  to  nervous  derange- 
ment. Pain  not  due  to  distinct  patho- 
logical lesions  forms  the  chief  indication 
for  its  administration,  and  relief  is  usu- 
ally obtained  promptly.  H.  E.  Lewis 
(Merck's  Archives,  July,  1900). 

In  tetanus  cannabis  Indica  Las  been 
found  very  efficacious  at  times,  and  in 
those  cases  wherein  it  is  not  curative  it 
seldom  fails  to  afford  some  measure  of 
relief. 

Hat  Fever. — The  usefulness  of  hemp 


in  allaying  morbid  irritability  of  the 
nervous  system  is  such  that  it  has 
been  suggested  for  employment  in  the 
form  of  vasomotor  coryza  popularly 
denominated  "hay  fever"  or  "hay 
asthma";  but  there  seems  to  have  been 
no  critical  trial  thereof.  The  idea, 
however,  is  both  commendable  and 
rational,  and  worthy  of  experiment. 
Cannabis  is  often  efficacious  in  other 
asthmas,  either  given  by  the  mouth  or 
burned  and  its  fumes  inhaled. 

Delirium  Tremens.  —  In  delirium 
tremens  the  drug  is  often  most  satisfac- 
tory; here  its  action  resembles  opium 
and  wine,  but  is  much  more  certain.  It 
produces  a  great  change  of  mind  in  the 
patients,  readily  dissipates  the  horrors, 
quiets  nerve-hyperffisthesia,  and  con- 
duces to  cheerfulness;  but  great  dis- 
crimination is  necessary  in  application. 

Uterine  Hemorrhage. — In  menor- 
rhagia  and  other  uterine  fluxes  hemp  is 
often  invaluable  if  judiciously  employed; 
and  so,  too,  it  may  prove  valuable  in 
impending  abortion.  Mention  has  al- 
ready been  made  of  its  power  upon  the 
gravid  womb  inactive  through  inertia, 
and  it  is  equally  efficacious  as  a  prevent- 
ive of  post-partuni  haemorrhage  or  as  a 
remedy  after  "flowing"  has  begun,  but 
requires  to  be  given  in  full  dose  and 
sometimes  in  conjunction  with  ergot. 
Here  half-drachm  or  even  drachm  doses 
of  the  fluid  extract  may  be  exhibited, 
since — strange  to  say — in  such  cases  it 
never  exhibits  the  ordinary  physiological 
effects;  there  is  no  excitement,  no  in- 
toxication, and  no  tendency  to  somno- 
lence; only  a  feeling  of  quiet  well-being, 
and  that  the  condition  is  one  of  perfect 
safety. 

Effect  upon  Reproductive  Organs. 
— Cannabis,  too,  is  especially  available 
for  sensitive  ovaries.  Indeed,  it  seems 
sedative  to  all  the  pelvic  contents;    and 


CANNABIS  INDICA.    THERAPEUTICS. 


681 


it  is  thus  that  it  acts  as  an  aphrodisiac 
by  allaying  functional  nerve  irritation, 
not,  as  has  been  supposed,  by  stimulating 
erethism;  and  yet  the  latter  effect  may 
be  had  from  large  doses,  but  is  apt  to 
be  most  fleeting  or  else  assume  the  form 
of  a  priapism  in  man  and  nymphomania 
in  woman  that  is  not  gratified,  much 
less  satisfied,  by  sexual  indulgence. 

It  exerts  a  very  marked  effect  upon 
the  reproductive  apparatus.  In  the 
early  stages  of  gonorrhoea  small  doses 
combined  with  gelsemium  will  subdue 
the  disease  much  sooner  and  more  safely 
than  the  old  method  of  ruining  the 
digestive  powers  with  large  doses  of 
copaiba  and  turpentine.  Combined  with 
gelsemium  it  subdues  inflammation  of 
mucous  tissue.  In  spermatorrhoea  in 
highly  nervous  subjects  it  is  especially 
valuable.  It  will  do  good  service  com- 
bined with  pareira  brava  in  cases  of 
irritable  bladder.  Goss  ("Text-book  of 
Mat.  Med.,  Phar.,  and  Special  Ther.," 
'89). 

Choleea.  —  In  the  Orient  it  is  a 
favorite  remedy  for  epidemic  cholera; 
patients  in  actual  collapse  have  revived 
after  taking  a  full  dose.  It  seems  to 
stimulate  the  nervous  centres  at  a  period 
when  their  influence  is  all  but  suspended. 
It  is  by  no  means  a  universal  panacea  as 
regards  this  malady,  and  seems  to  little 
afl:ect  the  dark  races,  probably  because 
they  are  generally  more  or  less  habitu- 
ated to  its  use. 

Cardiac  Diseases. — In  violent  palpi- 
tations of  the  heart  the  drug  is  often 
markedly  remedial,  especially  when  the 
non-utility  of  all  other  agents  has  been 
proved.  The  late  Dr.  Christison,  of 
London,  especially  extolled  it;  he  em- 
ployed it  in  a  large  number  of  instances 
with  unequivocal  effect,  and  by  its  aid 
succeeded  in  relieving  a  case  of  twenty- 
one  years'  standing. 

Skin  Diseases. — In  eczema  and  other 
cutaneous    disorders   accompanied    with 


intolerable  itching,  cannabis  gives  relief 
when  local  treatment  does  not,  but  it 
must  be  employed  in  a  way  to  secure  its 
full  and  prompt  effect. 

In  skin  diseases  associated  with  intense 
itching,  particularly  senile  pruritus, 
where  local  applications  fail  to  relieve, 
cannabis  Indica  is  often  used  with  great 
benefit;  and,  though  there  are  rarely 
any  untoward  manifestations,  it  is  best, 
perhaps,  to  give  at  first  in  small  doses 
and  then  gradually  increase.  Mackenzie 
(La  Sem.  M6d.,  No.  14,  '94;  Univ.  Med. 
Mag.,  Dec,  '94). 

Digestive   Disorders.  —  In   certain 
diseases  of  the  stomach  and  digestive 
apparatus  the  drug  is  often  available, 
and  preferable  to  opium,  in  that  it  does 
not  inhibit  (but,  instead,  increases)  ap- 
petite; does  not  interfere  with  the  secre- 
tions of  either  pancreas  or  liver,  and  does 
not  constipate  or  .check  renal  secretion. 
Cannabis   Indica   is   very   valuable   in 
the   treatment   of   gastric   neurosis    and 
gastric  dyspepsia.    It  allays  painful  sen- 
sation and  improves  appetite.    It  has  no 
action    on    atony    or    dilatation    of    the 
stomach,  but  is  of  great  service  in  pro- 
moting   stomach   digestion    in    cases    of 
hyperchlorhydria ;    in  anachlorhydria  it 
acts  feebly.     Intestinal  digestion  is  also 
improved  by  its  use.     On  the  whole,  it 
may  be  considered  as  a  true  sedative  of 
the    stomach,    and    it   lacks    the    disad- 
vantages that  accrue  to  opium,  bismuth, 
potassium      bromide,      antipyrine,      etc. 
Germain  See   (Bull.  G6n.  de  Th6r.,  July 
29,  '90). 

In  anorexia  following  exhaustive  dis- 
eases— where  there  is  repugnance  and 
intolerance  of  food  in  almost  every  form 
that  is  not  relieved  by  acids,  nux 
vomica,  and  bitters — from  5  to  10 
minims  of  tincture  of  cannabis,  or  14 
to  V2  grain  of  the  solid  extract,  given 
thrice  daily  before  meals,  often  brings 
back  the  appetite  in  two  or  three  days. 
In  dyspeptic  diarrhoea  also,  and  the 
first  months  of  true  tropical  diarrhoeas, 
it  is  often  of  great  service.  Tropical 
diarrhoea  is  primarily  and  essentially  a 
disease  of  the  liver,  and  mercury  should 


682 


CANNABIS  INDICA. 


CANTHARIDES. 


be  administered  to  medicate  that  organ, 
while  the  cannabis  acts  by  diminishing 
the  irritability  and  excessive  peristalsis 
of    the    intestines.       McConnell     (Prac, 
London,  Feb.,  '88). 
Cephalalgia. — Many    have    praised 
the  drug  in  the  treatment  of  headache, 
even  the  severe  forms   attending  cere- 
bral growths,  or  where  the  cephalalgia  is 
dependent  on  urasmie  poisoning. 

It  is  almost  a  specific  for  that  con- 
tinuous form  of  headache  which  begins 
in  the  morning  and  lasts  all  day,  the 
pain  being  generally  dull  and  diffuse, 
but  marked  by  occasional  exacerbations. 
Mackenzie  (La  Sem.  Med.,  No.  14,  '94). 
Cannabis  Indica  is  an  excellent 
remedy  for  megrim,  or  sick  headache, 
and  it  is  somewhat  surprising  that  it  is 
not  more  frequently  employed ;  the  ex- 
tract may  be  given  in  doses  of  from  Vj 
to  Va  grain  in  the  form  of  a  pill.  When 
the  patient  suffers  constantly  from 
headache,  or  is  liable  to  an  attack  on 
the  slightest  provocation,  a  pill  may  be 
taken  three  times  a  day  for  many  weeks 
at  a  time  without  the  slightest  fear  of 
the  production  of  any  untoward  effect. 
Should  the  patient  not  speedily  obtain 
relief,  care  must  be  taken  to  ascertain 
that  the  extract  employed  is  physio- 
logically active.  Excellent  results  are 
often  obtained  by  administration  of  pills 
containing  4  grains  of  cannabin  tannate, 
one  being  given  three  times  a  day  after 
meals.  Murrell  ("Manual  of  Phar.  and 
Ther.,"  '96). 

Cannabis  Indica  is  an  invaluable  rem- 
edy in  the  treatment  of  disturbances  of 
the  sensory  centres.  It  is  one  of  the 
best  remedies  in  headaches  of  many 
kinds,  and  is  especially  useful  in  cephalic 
sensations  so  common  in  individuals  of 
neurotic  habit.  Tincture  or  fluid  extract 
preferred.  Five  to  10  drops  of  fluid  ex- 
tract may  be  taken  on  moist  sugar,  swal- 
lowed with  a  draught  of  water.  Angel 
Money  (Australasian  Med.  Gaz.,  Feb., 
1900). 

EHEUjrATiSM.  —  Here  cannabis  has 
been  lauded  for  both  its  analgesic  and 
curative  effects,  yet  it  is  questionable  if 
it    deserves    the    encomiums    bestowed; 


but  it  may  tend  to  alleviate  pain,  and  it 
also  increases  appetite  and  mental  cheer- 
fulness. 

Respieatoet  Diseases. — It  is  also  a 
capital  sedative  to  the  upper  respiratory 
tract,  and  is  a  favorite  factor  in  many 
cough-mixtures;  Fothergill  long  ago 
commended  its  use  in  phthisis  pulmo- 
nalis. 

It  most  perceptibly  relieves  the 
cough ;  it  aids  by  its  stimulating  and  ex- 
hilarating qualities,  and  supplies  a  place 
that  cannot  be  filled  by  any  other 
drug.    Lees  (Med.  Rec,  vol.  xlix,  '95). 

Renal  and  Ueinaey  Maladies. — 
It  is  also  frequently  recommended 
in  Bright's  disease  where  the  urine  is 
tinged  with  blood,  and  upheld  as  an 
almost  specific  for  urethral  spasm,  for 
chordee,  and  the  acute  stage  of  gonor- 
rhoea; also  in  gonorrhoea  and  vesical 
irritation,  and  in  spermatorrhoea. 

CANTHARIDES.— The  blister-beetle, 
or  "Spanish  fly,"  a  coleopterous  insect, 
also  called  lytta,  is  collected  in  Russia, 
Sicily,  and  Hungary,  but  is  also  found  in 
Spain,  France,  Germany,  and  other  parts 
of  Europe.  Representatives  are  found  in 
various  parts  of  the  world,  notably  in  the 
Levant  and  eastward,  in  Senegal,  South- 
ern and  Central  America,  and  in  Chile. 
The  insect  is  about  an  inch  long,  per- 
haps one-fourth  inch  broad,  flatfish, 
cylindrical,  with  filiform  antennae;  it  is 
black  in  upper  part,  with  long  wing-cases, 
and  has  large  membranous,  transparent, 
brownish  wings;  elsewhere  of  a  shining, 
coppery-green  hue.  The  powder  is 
grayish-  or  blackish-  brown,  containing 
green,  shining  particles,  with  strong,  dis- 
agreeable odor  and  acrid  taste;  is  soluble 
in  alcohol.  Cantharides  is  often  adulter- 
ated, especially  when  powdered  with 
other  beetles,  exhausted  flies,  and  ground 
gum-resin  euphorbium;  but  these  can  be 
detected,  or  at  least  surmised,  by  testing 


CANTHAlilDES.     PKEPAHATIONS  AND  DOSES. 


G83 


for  the  yield  of  cantharidiue,  which 
should  not  be  less  than  4  per  cent.;  it 
rarely  exceeds  5.5  per  cent. 

Preparations  and  Doses. — Cantharides, 
powdered,  V^  to  V2  grain — not  tit  to  be 
employed  in  crude  form. 

Cantharides  cerate,  for  blisters  only. 

Cantharides  cerate  (made  with  alco- 
holic extract),  external  only. 

Cantharides  tincture  (5  per  cent.),  1 
to  30  minims. 

Cantharides  vinegar,  external  only. 

Cantharidine,  not  employed. 

Cantharidate  of  cocaine,  Vjo,,  to  Vioo 
grain. 

Cantharidate  of  potassium,  Vioo  to 
V200  grain;   hypodermically  only. 

Cantharidal  collodion. 

Cantharidal  liniment. 

Cantharidal  oil,  external  only. 

Cantharidal  ointment. 

Cantharidal  paper  (blister-paper). 

Cantharidal  plaster  with  pitch. 

Cantharidal  warming  plaster. 

The  powder  of  cantharides  is  too  acrid 
and  irritating  to  be  employed  except  in 
very  minute  doses  or  well  covered  by 
other  substance,  and,  even  then,  pref- 
erably in  capsules.  Its  chief  employ- 
ment is  as  the  component  part  of  cerates, 
liniments,  ointments,  and  other  epi- 
spastic  galenicals. 

Cantharides  cerate,  "blister-plas- 
ter," or  "flying  blister,"  is  made  by  mix- 
ing 96  grains  of  finely-powdered  "flies," 
60  grains  of  yellow  wax,  68  grains  of 
prepared  suet,  24  grains  of  resin,  and  48 
grains  of  lard,  the  whole,  when  thor- 
oiTghly  incorporated,  being  spread  on  a 
suitable  piece  of  sheep-skin  or  adhesive 
plaster. 

The  "warming"  plasters  are  of 
two  kinds.  One  is  obtained  by  adding,  to 
a  strong  infusion  of  4  ounces  of  canthar- 
ides, 4  ounces  each  of  oil  of  nutmeg, 
yellow  wax,  and  pure  resin;    and  then 


incorporating  with  3  '/^  pounds  of  resin- 
plaster  and  2  pounds  of  soap-plaster,  the 
last  two  being  previously  heated;  it 
should  have  a  decidedly-yellow  hue. 
The  other,  also  termed  cantharidal 
pitch-plaster,  is  composed  of  Barbadoes 
pitch,  to  which  ordinary  cantharidal 
cerate  is  added  to  the  amount  of  8  per 
cent. 

Cantharidal,  or  "blistering,"  col- 
lodion is  a  thick  liquid  formed  by  add- 
ing 1  ounce  of  pyroxylin  (gun-cotton) 
to  20  ounces  of  the  blistering  liquid 
known  as  cantharidal  liniment;  this 
latter  is  obtained  by  macerating  for 
twenty-four  hours  8  ounces  of  canthar- 
ides in  4  ounces  of  acetic  acid,  then 
percolating  the  mixture  with  a  pint  of 
ether  until  20  ounces  are  obtained. 
Another  liniment  is  composed  of  15 
parts  of  cantharides  in  sufficient  turpen- 
tine to  make  100  parts. 

Cantharidal,  blistering-,  or  epi- 
spastic  paper  is  merely  a  good  wax-  or 
paraffin-  paper  coated  on  one  side  with 
a  mixture  of  4  ounces  of  white  wax,  1  ^/j 
ounces  of  spermaceti,  2  ounces  of  olive- 
oil,  6  drachms  of  resin,  8  drachms  of 
cantharides,  and  6  ounces  of  water, — 
the  whole  heated  together, — then  adding 
2  drachms  of  Canada  balsam  after  reject- 
ing the  watery  liquid. 

By  digesting  3  parts  of  cantharides  in 
10  parts  of  olive-oil  for  ten  hours  over 
a  water-bath,  cantharidal  oil  is  ob- 
tained. 

Cantharides  ointment  is  a  mixture 
of  1  ounce  of  the  flies  with  an  equal 
amount  of  yellow  wax  and  6  ounces  of 
olive-,  cotton-seed,  or  peanut-  oil. 

The  "vinegar"  may  be  prepared  by 
digesting,  at  200°  F.,  and  subsequent 
percolation,  2  ounces  of  cantharides,  18 
ounces  of  acetic  acid,  and  2  ounces  of 
glacial  acetic  acid. 

Cantharidine,  or  cantharidal   cam- 


CANTHARIDES.    PHYSIOLOGICAL  ACTION.    POISONING. 


phor,  is  found  in  glistening  rectangular 
prisms,  which  melt  at  318°;  heated 
higher  it  gives  off  a  heavy,  white,  very 
irritating  vapor,  condensing  unaltered  to 
crystals.  It  is  easily  soluble  in  acetone, 
sulphuric  acid,  and  glacial  acetic  acid, 
less  so  in  chloroform  (1  to  80),  very  little 
in  90-per-cent.  alcohol,  1  to  500  in  pe- 
troleum ether,  and  1  to  5000  in  water; 
the  aqueous  solution,  though  practically 
tasteless,  is  by  no  means  devoid  of  vesica- 
tory power  even  in  the  minutest  quanti- 
ties. Cantharidine  is  also  soluble  in 
fatty  oils  and  gives  an  acid  reaction  to 
very  sensitive  litmus-paper;  it  volatilizes 
at  100°.  It  likewise  combines  readily 
with  alkalies  to  form  soluble  salts.  If 
nitric  acid  is  added  to  eantharidinate  of 
sodium,  crystals  of  cantharidine  are  at 
once  precipitated. 

The  foregoing  paragraph  sufficiently 
explains  the  formation  of  cantharidate  of 
potassium,  which,  however,  seems  only 
to  have  had  an  ephemeral  existence. 

Cantharidate  of  cocaine  is  a  mixture 
of  cantharidate  of  sodium  and  cocaine 
muriate,  and  occurs  as  a  white,  inodor- 
ous, amorphous  powder  with  a  sharp 
taste,  readily  soluble  in  alcohol,  ether, 
petroleum  spirit,  and  hot  water.  Its 
uses  are  the  same  as  those  of  the  potas- 
sium salt. 

Physiological  Action. — All  species  of 
cantharides  are  powerfully  irritant  when 
applied  to  the  skin,  and  likewise  vesi- 
cant, these  two  properties  depending 
upon  the  cantharidine.  Internally  the 
drug,  can  be  given  properly  only  in  the 
form  of  tincture,  for  obvious  reasons 
(see  Poisoning),  though  the  powder  is 
sometimes,  though  rarely,  mistakenly 
employed;  and  even  the  tincture  should 
be  employed  only  in  connection  with 
copious  diluents  and  demulcents.  Suit- 
ably administered,  the  tincture  is  a  stim- 
ulant diuretic,  and  it  appears  also  to  ex- 


ert a  specific  influence  upon  the  mucous 
membrane  of  the  genito-urinary  sys- 
tem, particularly  the  neck  of  the  bladder. 
In  larger  doses  it  is  highly  irritant,  and 
it  is  not  an  uncommon  accident  for  suf- 
ficient of  the  drug  to  be  absorbed  during 
applications  to  the  skin  to  cause  great 
irritation  of  the  kidneys,  as  evidenced  by 
painful  micturition  and  bloody  urine. 

The  inflammation  produced  by  can- 
tharides begins  in  the  gloraeruli  and  not 
in  the  straight  tubes.  The  first  condi- 
tion of  the  kidneys  noticed  after  the 
administration  of  the  drug  is  extravasa- 
tion of  leucocytes  into  the  glomeruli 
and  an  exudation  of  a  fibrous  matrix. 
This  is  followed  by  filling  of  the  glom- 
eruli and  the  proximate  tubules  with  a 
granular  fluid,  after  which  comes  swell- 
ing of  the  cells  of  the  capsule.  Next 
in  order  swelling  of  the  cells  of  the 
collecting  tubes  and  of  the  whole  uri- 
nary tubule  is  observed.;  and  in  the  last 
stage  multiplication  of  the  cells  of  the 
straight  collecting  tubes  which  are 
thrown  off  so  that  their  lumen  becomes 
filled  with  exuded  cells.  Murrell,  Lond. 
("Manual  of  Mat.  Med.  and  Therap.," 
'96). 

Lahousse  finds  that  cantharides  afi:eets 
simultaneously    the   Malpighian    bodies, 
the   renal   tubules,   and   the   matrix   of 
the  kidney.    The  Malpighian  vessels  are 
greatly  congested;    albumin,  leucocytes, 
and   a   few  red   corpuscles   escape;    the 
epithelium   covering   the    vessels    lining 
the  capsule  swell  and  desquamate;   the 
endothelium   of   the   vessels   swells   and 
may  choke  their  lumen,  the  tubule-cells 
swell,   become   granular,   and   die.     The 
tubules  contain  hsemoglobin  in  the  form 
of  brilliant-red  homogeneous   cylinders. 
Leucocytes     escape     into     the     matrix. 
Other    observers    hold    that    the    Mal- 
pighian   bodies    are    alone,    or    chiefly, 
aflfected.    Ringer  and  Sainsbury  ("Hand- 
book of  Therap.,"  '97). 
Cantharidal  Poisoning. — The  drug  in 
non-medicinal  doses  is  an  acrid,  corrod- 
ing poison,  the  chief  symptoms  being  a 
burning  sensation  in  the  throat,  violent 
pains  in    stomach    and    bowels,    nausea. 


CANTHARIDES.     POISONING.     TREATMENT.     THERAPEUTICS. 


685 


vomiting,  and  purging, — the  dejections 
being  frequently  bloody  and  purulent, — 
great  heat  and  irritation  of  the  urinary 
organs,  sometimes  accompanied  by  pain- 
ful erethism,  and  in  the  male  painful 
priapism,  quick  and  hard  pulse,  labo- 
rious breathing,  convulsions,  tetanus, 
delirium,  and  syncope.  The  morbid  ap- 
pearances are  principally  inflammation 
and  erosion  of  the  stomach.  If  the  flies 
or  powder  have  been  ingested,  character- 
istic debris  will  be  found  adhering  to  the 
mucous  coat  of  the  stomach  and  in- 
testines, and,  if  recent,  mixed  with  the 
contents  of  the  prima  vice  generally; 
powder  of  cantharides  has  been  identi- 
fied in  the  stomach  nine  months  after 
death;  there  are  also  discoverable  the 
marks  of  violent  inflammation  through- 
out the  urinary  organs;  but  such  are 
usually  most  prominent  when  the  poi- 
soning is  not  fatal.  The  kidnej's  are 
frequently  gorged  with  blood,  as  is  the 
brain. 

Treatment  of  Cantharidal  Poisoning. — 
There  is  no  known  antidote  for  this 
drug,  and  all  toxic  cases  require  to  be 
treated  in  consonance  with  the  indica- 
tions afforded  by  each  individual  case; 
it  frequently  can  be  little  beside  pallia- 
tive. The  promotion  of  free  vomiting  is 
generally  imperative,  further  fostering 
by  means  of  warm  demulcents  and  dilu- 
ents; diluents  are  in  order  even  after 
emesis  has  accomplished  all  possible. 
Bland  oils  have  been  suggested,  but  these 
are  dangerous,  since  they  are  apt  to  sep- 
arate the  cantharidine,  which  is  very 
soluble  therein,  and  thereby  enhance  and 
hasten  toxicity.  Opium,  even  chloro- 
form by  inhalation,  is  sometimes  de- 
manded to  allay  the  excruciating  suf- 
fering or  to  control  convulsions.  Opium 
enemas  and  frictions  also  will  find  place. 
Camphor  often  alleviates  the  most  dis- 
tressing  symptoms,   and   bromides   may 


be  required.  The  smallest  amount  of 
tincture  known  to  have  induced  fatality 
is  1  ounce;  of  the  powder,  48  grains. 

Case  of  cystitis  caused  by  the  u.se  of 
cantharides  as  a  blister.  The  symptoms 
were  of  considerable  severity.  Mono- 
bromated camphor  was  given  both  by 
tlie  mouth  and  by  enema;  but  no  relief 
was  obtained.  The  condition,  however, 
yielded  promptly  to  the  influence  of 
cocaine.  Albarran  (Lancet,  Lond.,  Dec. 
12,  '92). 

Therapeutics. — The  internal  admin- 
istration of  cantharides  finds  less  favor 
than  it  did  half  a  century  back,  doubt- 
less because  of  the  many  accidents  that 
have  followed  its  employment.  Some 
years  ago  the  tincture  was  lauded  as  a 
powerful  depressant,  contrastimulant, 
and  antiphlogistic,  and  advised  to  be 
used  in  acute  inflammation,  but  even  the 
Italian  physicians,  who  were  the  strong- 
est supporters  of  the  drug  in  this  con- 
nection, soon  abandoned  it  for  other  and 
more  safe  medicaments.  At  present  it 
finds  its  chief  employment  in  the  man- 
agement of  genito-urinary  disorders,  and, 
among  French  physicians,  in  diseases  of 
the  skin  and  scalp.  The  late  Dewees 
considered  the  tincture  in  doses  of  10 
minims,  gradually  increased  to  twice  or 
thrice  this  amount,  to  be  an  absolute 
specific  in  amenorrhcea;  but  how  he 
avoided  symptoms  of  strangury,  when 
administering  the  larger  doses,  consid- 
ering the  potent  nature  of  the  remedy,  is 
something  of  a  mystery. 

Incon-tinence  of  Urine.  — ■  Where 
this  depends  upon  an  atonic  state  of  the 
bladder,  the  tincture  may  often  be  given 
with  excellent  effect;  it  appears  to  act 
locally,  stimulating  the  parts  and  restor- 
ing a  healthy  tone  to  the  bladder. 

Small  doses  of  cantharides  may  be 
relied  upon  to  cure  the  slight  inconti- 
nence of  urine  which,  with  women,  is 
frequently  associated  with  paroxysmal 
cough.      Half    a    drachm    is    prescribed 


686 


CANTHARIDES.    THERAPEUTICS. 


with  4  ounces  of  water,  and  of  this  a 
teaspoonful  is  talcen  hourly.  It  rarely 
fails  to  effect  a  cure  in  twenty-four 
hours.  Murrell,  Lond.  ("Manual  of 
Mat.  Med.  and  Therap.,"  '96). 

Women,  especially  middle-aged  women, 
often  suffer  from  a  frequent  desire  to 
pass  water,  or  an  inability  to   hold  it 
long;  sometimes  this  occurs  only  in  the 
day   on  moving  about.     In  these  cases 
micturition  may  cause  no  pain,  neither 
is    there    likely    to    be    any    straining, 
sneezing,  or  coughing.     Sometimes  both 
sets  of  symptoms  are  present,  due  ap- 
parently to  weakness   of  the  sphincter 
of  the  bladder.     One   or   two   drops   of 
tincture   of   cantharides,   three   or   four 
times  a  day,  will,  in  many  cases,  afford 
great  relief  to  these  troubles,  and  some- 
times    cure     them     with     astonishing 
rapidity,  even  when  the  symptoms  have 
lasted  for  months  or  years.    Ringer  and 
Sainsbury  ("Handbook  of  Therap.," '97). 
Ueinaht   Suppression.  —  The   drug 
has  also  been  recommended  as  a  remedy 
for  suppression  of  urine,  but  on  what 
physiological   grounds  it  is   difficult   to 
imagine;   the   evidence    afforded   is   too 
flimsy    to    be    worthy    of    consideration 
from  even  an  empirical  stand-point. 
•    As  AN  Aphrodisiac. — In  the  treat- 
ment of  impotence  the  drug  has,  espe- 
cially of  late  years,  received  its  greatest 
employment,    and    the    affirmative  evi- 
dence   is   not    without   weight,    though 
many  have  experienced  nothing  but  fail- 
ure from  its  use.    Sloughing  of  the  penis 
may  occur  from  the  employment  of  can- 
tharides, even  in  what  are  deemed  safe 
medicinal  doses. 

Internally  employed,  rarely,  in  doses 
of  4  to  10  drops  three  times  a  day  in 
a  mucilaginous  mixture  for  impotence; 
but  must  be  used  carefully  because  of 
the  danger  of  causing  albuminuria. 
Roth   ("Mod.  Mat.  Med.,"  '95). 

Bmmenagogue  and  Abortifacient. 
— Both  these  properties  are  claimed  for 
cantharides,  and  it  is  generally  admitted 
that  the  claims  possess  a  measiire  of 
truth,  but  also  that  its  employment  for 


either  purpose  is  little,  if  any,  less  than 
criminal.  Sloughing  of  the  labia  is  a 
frequent  result  from  this  use  of  the  drug. 
Urethral,  Prostatic,  and  Cystic 
Maladies.  —  The  drug  has  been  em- 
ployed in  all  these  conditions  with,  at 
times,  very  apparent  benefit;  but  that 
its  application  is  by  no  means  universal 
is  evidenced  by  the  fact  that  it  frequently 
fails.  The  conditions  when  it  is  likely 
to  prove  of  value,  therefore,  require  to 
be  carefully  considered  and  studied  out. 
It  certainly  is  of  no  value,  of  itself,  in 
syphilis,  but  given  in  conjunction  with 
mercury  salts  it  materially  enhances 
their  activity. 

After  its  separation  by  the  kidneys 
cantharides  acts  as  an  irritant  to  the 
urinary  tact,  and  it  may  be  employed 
for  this  action  in  cystitis,  in  gonorrhoea, 
and  in  gleet.  One  drop  of  the  tincture, 
though  5  are  sometimes  required,  should 
be  given  three  or  four  times  a  day ;  this 
treatment  is  particularly  useful  in  cases 
where  there  is  a  frequent  desire  to  make 
water,  accompanied  by  great  pain  in 
the  prostate  gland  and  along  the 
urethra,  while  at  other  times  severe 
twinges  of  pain  are  felt  in  the  same 
parts.  The  urine,  under  these  circum- 
stances, may  be  healthy,  or  it  may  con- 
tain an  excess  of  mucus  or  even  a  small 
amount  of  pus.  A  drop  of  the  tincture, 
three  times  daily,  will,  in  the  majority 
of  instances,  abate  or  remove  chordee. 
Ringer  and  Sainsbury  ("Hand-book  of 
Therap.,"  '97). 

Diseases  of  Kidney. — As  a  Diuretic. 
— A  half-century  ago,  on  the  Continent 
of  Europe,  tincture  of  cantharides  was 
largely  employed  in  albuminuria,  begin- 
ning with  small  doses  and  gradually  in- 
creasing to  60  minims,  and  it  is  authori- 
tatively declared  that  this  procedure  was 
often  attended  with  decided  benefit;  the 
caution  is  given,  however,  that  it  is  not 
always  sitccessful,  and  that,  moreover,  it 
is  a  dangerous  remedy  in  the  hands  of 
the  inexperienced.     In  granular  disease 


CANTHARIDES.     THERAPEUTICS. 


687 


of  the  kidney,  too,  the  drug  has  been 
most  favorably  mentioned,  particularly 
by  Copland,  the  author  of  a  famous 
"Dictionary  of  Practical  Medicine." 

The  drug  is  powerfully  diuretic  under 
certain  conditions,  but  is  not  a  desirable 
remedy  to  exhibit  by  itself;  it  is  a  most 
valuable  adjunct  to  digitalis,  however, 
when  this  latter  remedy  is  employed  for 
the  express  purpose  of  promoting  diu- 
resis. 

ScuBvx;  Cheoijic  "Whooping-cough. 
— These  are  two  more  maladies  for  which 
the  drug  has  been  employed,  but  with  no 
apparent  success;  and  in  whooping- 
cough  it  has  never  appeared  to  be  of 
benefit  except  when  combined  with  cin- 
chona and  opium. 

Skin  and  Scalp  Diseases. — In  lepra, 
eczema,  and  psoriasis  cantharides  still 
is  in  considerable  repute,  but  does  not 
secure  the  same  degree  of  form  that  ac- 
crued to  it  in  the  latter  part  of  the  last, 
and  early  part  of  the  present,  century. 
It  is  advised  that  the  tincture  be  given 
in  3-  to  5-drop  doses,  three  times  daily, 
the  amount  to  be  increased  by  5  drops 
every  six  or  eight  days,  until  the  limit 
of  tolerance  has  been  reached. 

Ear  Diseases. — In  deafness  depend- 
ing upon  a  thickened  state  of  the  drum- 
membrane,  and  where  there  is  much  ir- 
ritation of  the  external  meatus,  many 
practitioners  in  the  past  believed  they 
had  secured  great  benefit  by  applying 
a  strong  cantharidal  ointment — 1  to  2 
— below  and  behind  the  ear  thrice  daily. 

Nervous  and  Spinal  Disorders. — • 
In  epilepsy  cantharides  has  been  favor- 
ably mentioned,  and  was  at  one  time 
held  in  considerable  esteem  by  the  older 
practitioners,  but  it  does  not  appear  to 
possess  any  special  virtues  in  this  direc- 
tion. It  has,  however,  sometimes  seemed 
to  be  of  marked  benefit  in  paraplegia, 
but  only  when  it  exercised   a   diuretic 


effect.  Also  it  is  often  available  when 
there  is  serous  effusion  into  the  vertebral 
canal,  as  in  spinal  dropsy,  and  both  its 
internal  administration  and  application 
externally  in  the  form  of  blistering 
cerate  tends  to  promote  absorption  of 
the  effused  fluid. 

Eespiratory,  Cardiac,  and  Drop- 
sical Maladies. — Cantharides  is  occa- 
sionally administered  internally  with 
benefit  in  passive  dropsies  with  a  view  of 
stimulating  the  action  of  the  kidneys, 
but  it  is  inadmissible  in  sthenic  or  acute 
cases;  it  should  be  administered  in  con- 
junction with  some  other  diuretic,  how- 
ever, such  as  a  decoction  of  broom,  in- 
fusion of  digitalis,  or  sweet  spirit  of 
nitre.  In  the  form  of  blister  the  cerate 
is  also  xiseful  in  these  maladies,  as  well 
as  in  pericarditis,  pleuritis,  pneumonia, 
and  more  rarely  phthisis. 

Within  a  few  years  the  cantharidate 
of  potassium  has  been  employed  as  a 
remedy  for  pulmonary  and  laryngeal 
tuberculosis,  on  the  strength  of  some 
experiments  undertaken  by  Liebreich; 
also  the  cantharidate  of  cocaine.  Lie- 
breich's  theory  is  that  the  inflammatory 
processes  set  up  by  the  cantharidin  pro- 
duce a  transudation  of  sanguineous  mi- 
crobicidal serum. 

The  chief  points  to  be  decided  are 
whether  cantharidinates  have  any  ac- 
tion on  diseased,  particularly  tubercu- 
lous, tissues,  and,  if  so,  whether  this, 
effect  is  obtained  before  any  disturbance 
is  produced  in  other  organs,  such  as  the 
kidneys.  The  eantharidinate  gives  rise 
to  an  increased  exudation  from  the 
capillaries;  hence  its  beneficial  action; 
but  there  is  no  hypersemia.  Advanced 
tuberculosis,  however,  should  be  treated 
with  extreme  caution,  for  the  kidneys 
are  often  fattily  degenerated.  Improve- 
ment has  been  recorded  in  other  than 
tubercular  processes, — e.g.,  in  chronic 
laryngitis.  Any  local  application  of  a 
eantharidinate  is  not  rational,  as  it  only 
produces  irritation.     In  hundreds  of  in- 


CANTHARIDES. 


CATALEPSY. 


jeetions  made,  there  has  been  no  more 
danger  to  the  patient  than  from  the 
use  of  mercury  or  arsenic.  Liebreich 
(Therap.  Monat.,  June,  '92). 

Eecently,  Liebreich  and  others  have 
recommended  the  subcutaneous  use  of 
eantharidin  in  combination  with  alka- 
lies in  the  treatment  of  tuberculosis. 
While  the  value  of  this  method  is  still 
undetermined,  the  accumulated  testi- 
mony gives  little  encouragement  for  its 
employment  in  this  affection.  In  pneu- 
monia, pericarditis,  etc.,  cantharides  is 
a  most  useful  vesicant. 

Blisters.- — These  are  applied  to  es- 
tablish a  degree  of  inflammation  or  irri- 
tation on  the  surface  of  the  body,  and 
thus  to  substitute  a  mild  and  easily  man- 
aged disease  for  an  internal  and  intract- 
able one,  on  the  principle  that  two  sets 
of  inflammation  cannot  be  carried  on  at 
the  same  time:  a  theory  that  admits  of 
some  question;  to  stimulate  the  absorb- 
ents and  thus  cause  the  removal  of 
effused  fluids;  to  act  as  derivatives;  to 
stimulate  the  whole  system,  and  raise 
the  vigor  of  the  circulation.  A  few 
rules  flnd  universal  application  as  re- 
gards the  use  of  these  agents,  viz.:  Never 
apply  a  blister  at  the  beginning  of  in- 
flammation,— never  until  the  acute  stage 
has  been  subdued  by  other  means. 
Never  apply  where  the  skin  is  thin  or 
tender  nor  over  a  bony  prominence,  as 
great  irritation  will  result,  and  the  heal- 
ing will  be  slow  and  difilcult.  In  many 
instances,  as  in  acute  laryngitis,  it  is  not 
advisable  to  apply  a  blister  directly  over 
the  seat  of  the  disease,  as  it  sometimes 
aggravates  the  symptoms;  indeed,  a 
blister  is  often  more  efficacious  if  applied 
at  a  remote  point,  as  to  the  heel  in  sci- 
atica or  lumbago.  As  a  rule,  it  is  not 
advisable  to  allow  a  blister  to  remain  on 
the  part  to  which  it  is  applied  more  than 
two  or  three  hours,- — only  until  it  has 


produced  considerable  redness,  when  the 
process  may  be  completed  by  soft,  warm 
poultices.  A  blister  has  been  known  to 
produce  abortion  when  applied  to  the 
neck  or  chest  of  a  pregnant  woman. 
Blisters  applied  to  a  scorbutic  person  are 
apt  to  induce  ulceration  and  gangrene; 
and  the  same  is,  in  a  measure,  true  as 
regards  this  application  to  children,  who, 
as  a  rule,  bear  vesicants  badly.  Finally, 
the  danger  of  absorption  of  cantharides 
from  cantliaridal  vesicants,  sufficient  to 
induce  untoward  phenomena,  and  even 
toxicity,  should  always  be  considered. 
Violent  strangury  has  resulted  in  some 
instances  from  the  application  of  a  blis- 
ter to  the  penis  with  a  view  of  prevent- 
ing masturbation. 

CAPILLARY    BRONCHITIS.      See 

Pneitmonia,  Cataeehal. 

CARBOLIC  ACID.    See  Phenic  Acid. 

CARBUNCLE.  See  Suegical  Dis- 
eases OF  Skin. 

CARCINOMA.     See  TmiOES. 

CARDIAC  ANEURISM.  See  Aneu- 
rism. 

CARTILAGINOUS  TUMORS.     See 

TuiiOES,  Enchondeoma. 

CATALEPSY. — From  Gr.,  zaTd?.>7- 
-^(g,  seizure. 

Definition. — Catalepsy  is  not  a  dis- 
tinct disease,  but  a  symptom  of  a  disor- 
dered condition  of  the  highest  nerve- 
centres:  the  cerebral  cortex.  During 
the  attacks,  which  are  intermittent,  the 
nervous  system,  especially  the  lower,  is 


CATALEPSY.    VAPJETIES. 


689 


in  an  excitable  state;  the  higher  centres 
have  lost  control  over  the  lower;  the 
face  at  times  is  as  passive  and  expression- 
less as  that  of  a  marble  statue,  while  in 
some  cases  the  face  seems  to  indicate 
mental  agitation;  there  is  impairment, 
or  apparent  loss,  of  consciousness,  vo- 
lition, and  sensation;  the  patient  lies, 
sits,  or  stands  with  muscles  in  a  state  of 
tonic  or  rigid  immobility,  and  if  the  head 
or  limbs  are  placed  by  an  attendant  in 
awkward,  or  what  are  usually  uncomfort- 
able, positions,  they  may  remain  so  for 
an  indefinite  period,  minutes  or  hours, 
without  any  apparent  voluntary  effort  or 
evidence  of  fatigue  on  the  part  of  the 
patient. 

All  these  manifestations  represent 
but  a  series  of  nervous  phenomena  in- 
dicating a  deranged  condition  of  the  nor- 
mal functioning  power  of  the  general 
nervous  system;  we  are  therefore  pre- 
pared to  learn  that  in  a  few  cases  it  may 
be  the  only  obtrusive  evidence  of  disease; 
that  it  may  occur  associated  with  hys- 
teria, or  that  it  probably  may  be  one  of 
the  manifestations  of  this  affection;  that 
it  may  be  an  epiphenomenon  of  certain 
organic  diseases  of  the  brain,  such  as 
abscess,  tumor,  softening,  meningitis, 
haemorrhage,  etc.;  that  it  may  be  found 
in  epilepsy,  insanity,  chorea,  or,  in  fact, 
in  almost  any  condition  of  the  nervous 
system  in  which  the  inhibitory  or  con- 
trolling power  of  the  higher  nerve-cen- 
tres over  the  lower  is  greatly  impaired 
or  lost  during  the  attacks. 

Varieties. — As  to  the  varying  condi- 
tions under  which  the  phenomena  may 
be  manifested,  with  modifications  of  the 
symptoms  in  different  cases,  those  who 
have  regarded  catalepsy  as  a  distinct  dis- 
ease, sui  generis,  have  spoken  of  "true" 
and  "false"  catalepsy:  catalepsia  vera 
and  catalepsia  spuria.  With  most  of 
these  writers  there  is  but  one  form  of 

1- 


catalepsy:  that  in  which  the  limbs  or 
any  fl.exible  portions  of  the  body  present 
a  condition  likened  to  a  figure  of  soft  or 
easily-molded  was  (so-called  flexibilitas 
cerea),  in  which  the  parts,  without  any 
apparent  voluntary  effort  on  the  part  of 
the  patient,  remain  for  an  indefinite 
time  in  the  positions  in  which  they  may 
be  placed. 

My  individual  impression  is  that  cata- 
lepsy, unassociated  with  organic  disease, 
denotes  an  hysterical  condition,  and  is 
then  one  of  the  numerous  manifestations 
of  hysteria  or  an  affection  closely  allied 
to  it.  In  some  cases  the  cataleptic  phe- 
nomena may  be  the  only  evidence  of  dis- 
ease, but  this  is  so  rare  that  some  observ- 
ers have  never  met  with  an  example. 

It  may  probably  be  placed  between 
epilepsy  and  hysteria  in  the  scale  of 
maladies,  but  nearer  the  latter  than  the 
former,  and,  as  regards  the  nature  of  its 
chief  feature,  it  may  be  regarded  as 
essentially  one  of  the  motor.  But  there 
is  also  distinct  interference  with  the  in- 
tellectual processes,  and  interruption  of 
the  connection  between  the  will  and  the 
motor  centres.  W.  K.  Gowers  ("Quain's 
Die.  of  Med.,"  vol.  i,  p.  285). 

[It  is  no  more  surprising  that  catalepsy 
should  occur  from  organic  disease  of  the 
brain  than  that  hysteria  should  manifest 
itself  under  similar  circumstances,  and, 
in  some  instances,  become  so  prominent 
as  to  lead  the  unwary  observer  to  mis- 
take a  tumor  or  some  other  lesion  for 
the  functional  disturbance.  Indeed,  it 
seems  to  me  that  this  is  another  reason 
for  regarding  catalepsy  as  one  of  the 
manifestations  of  hysteria  or  its  twin- 
sister.  In  Colorado  hysteria  in  its  ex- 
aggerated forms  is  almost  unknown. 
During  a  residence  of  fourteen  years  in 
this  State  I  have  not  met  with  a  single 
case  of  catalepsy  in  which  the  cataleptic 
phenomena  were  prominent  or  consti- 
tuted the  sole  evidence  of  the  nervous 
disturbance.  During  my  residence  here 
my  practice  has  been  almost  entirely 
limited  to  the  diseases  of  the  nervous 
system    (mental    and    physical),    and    I 


690 


CATALEPSY.    SYMPTOMS. 


have  seen  eases  from  nearly  every  por- 
tion of  the  State,  and  many  from  the 
adjoining  States  and  territories.  If 
ctlier  observers  shall  find  that  so-called 
true  catalepsy  is  only  found  in  places 
favorable  for  the  development  of  hys- 
teria in  its  most  pronounced  type,  it  will 
show,  at  least,  that  the  phenomena  of 
the  former  are  closely  associated  with 
those  of  the  latter,  if,  indeed,  they  are 
not  a  part  of  them.  Further,  the  course, 
duration,  prognosis,  and  treatment  of 
catalepsy  are  almost  identical  with  those 
of  hysteria.     J.  T.  Eskkidge.] 

I  shall  first  endeavor  to  give  a  descrip- 
tion of  the  cataleptic  phenomena  in  cases 
in  which  they  occur  as  the  principal  or 
only  symptoms  of  the  nervous  disorder, 
then  as  they  are  found  associated  with 
other,  and  often  graver,  nervous  de- 
rangements. 

Symptoms. — The  symptoms  of  cata- 
lepsy are  not  easily  described,  as  the 
phenomena  observed  are  seen  under  so 
many  different  conditions.  In  a  very 
few  cases  the  cataleptic  phenomena  are 
the  only  obtrusive  evidences  at  the  time 
of  the  attack  of  a  disordered  state  of  the 
nervous  system;  in  a  second  class  the 
symptoms  of  hysteria  are  so  pronoiinced 
that  it  is  difficult  to  determine  which  is 
the  real  affection;  in  a  third  the  cata- 
leptic phenomena  form  a  part  of  a  graver 
disease,  such  as  insanity,  epilepsy,  or 
organic  trouble  of  the  brain;  in  a  fourth 
the  nervous  symptoms  are  the  results  of 
certain  poisons  or  toxsemic  states;  and 
finally  in  a  fifth  the  peculiar  nervous 
disturbances  are  a  part  of  the  phenomena 
witnessed  in  a  state  of  hypnosis  which 
has  been  introduced  by  a  method  that 
greatly  agitates  and  excites  the  higher 
nerve-centres.  I  shall  first  try  to  give  a 
description  of  catalepsy  as  free  from 
complications  as  possible,  then  will  fol- 
low references  to  cataleptic  phenomena 
as  met  with  in  association  with  other 
nervous  disorders. 


Catalepsy  is  essentially  a  paroxysmal 
or  intermittent  affection.  For  its  devel- 
opment in  its  typical  form  it  probably 
always  requires  on  the  part  of  the  sub- 
ject a  certain  predisposition,  an  unstable 
and  excitable  nervous  condition,  a  tend- 
ency to  hysterical  manifestations,  most 
prominent  among  which  is  hypersensi- 
tiveness  of  some  of  the  special  senses. 
The  paroxysms  vary  greatly  in  their 
severity  and  duration.  The  pronounced 
symptoms  usually  come  on  suddenly,  but 
these  are  often  preceded  by  headache, 
slight  hysterical  manifestations,  giddi- 
ness, gastric  symptoms,  or  hiccough. 
The  special  symptoms  are  ushered  in  by 
all  or  part  of  the  voluntary  muscles  sud- 
denly becoming  rigid,  the  limbs  remain- 
ing in  the  positions  in  which  they  were 
arrested  by  the  onset  of  the  attack. 

In  some  cases  the  arm  stops  in  the  act 
of  carrying  a  cup  to  the  mouth;  the 
latter  remains  open  and  the  whole  body 
assumes  a  fixed  position,  as  if  petrified. 
At  first  the  muscles  are  quite  rigid  and 
resist  strong  passive  motion;  but  soon 
the  rigidity  is  followed  by  a  soft,  wax- 
like state  of  the  muscles.  The  limbs 
may  then  be  placed  in  various  positions 
by  moderate  passive  motion,  and  in  these 
they  will  remain  for  several  minutes,  or 
even  for  hours  in  some  cases.  If  an  arm 
or  a  leg  is  placed  at  a  right  angle  with 
the  body,  with  no  support  except  that 
given  by  the  muscles  in  a  state  of  in- 
creased tension,  it  woidd  be  main- 
tained in  this  uncomfortable  position 
for  a  considerable  length  of  time;  but 
after  awhile  the  limb  from  force  of 
gravity  begins  gradually  to  descend. 
Two  important  observations  may  be 
made  at  this  stage  of  the  attack  that 
have  considerable  diagnostic  value.  One 
is  that  the  patient's  features  and  respira- 
tion show  no  evidence  of  fatigue  or  vol- 
untary effort,  and  the  other  is  that  if  a 


CATALEPSY.    SYMPTOMS. 


691 


weight  of  a  few  pounds  is  suspended  to 
the  limb,  or  passive  motion  is  exerted  to 
overcome  the  tension  of  the  muscles  that 
hold  the  limb  in  its  position,  the  mem- 
ber gradually  descends,  without  any  ex- 
tra effort  being  exerted  to  keep  it  from 
falling.  Consciousness  is  always  im- 
paired, and  sometimes  apparently  com- 
pletely lost,  from  the  first.  The  degree 
of  disturbed  consciousness  varies  in  dif- 
ferent cases.  In  some  cases  it  seems  to 
be  completely  abolished. 

[I  think  Dr.  C.  K.  Mills  is  right  in 
cautioning  against  haste  in  believing 
that  unconsciousness  is  complete  in  a 
given  case.     J.  T.  Eskkidqe.] 

In  a  few  cases  in  which  the  cataleptic 
condition  of  the  muscles  is  well  marked 
the  patient  makes  no  attempt  to  answer 
questions  or  to  move  when  the  skin  is 
irritated,  because  volition  is  in  abeyance; 
but  the  patient  may  know  everything 
that  goes  on  around  her.  The  pulse, 
temperature  and  respiration  are  slightly 
changed.  The  pulse  is  slow  or  normal; 
the  temperature  is  usually  a  little  sub- 
normal; sometimes  it  is  one  or  several 
degrees  below  the  normal;  respiration  is 
quiet,  shallow,  and  sometimes  almost  im- 
perceptible. The  face  is  pale,  the  eyes 
wide  open  and  looking  horizontally  for- 
ward. Sometimes  the  lids  are  partially 
or  gently  closed.  The  pupils  are  dilated, 
often  react  to  light  slowly,  but  in  some 
cases  they  show  no  response.  The  fundi 
and  optic  nerves  have  been  found  anas- 
mic,  according  to  ^.  A.  Hammond. 
The  features  frequently  present  a  blank 
or  placid  appearance,  but  in  some  cases 
they  show  evidences  of  mental  agitation. 
The  skin  is  often  very  cool  and  pale, 
especially  if  the  paroxysm  is  prolonged; 
this  with  the  almost  imperceptible  res- 
piration and  expressionless  features, 
open  eyes,  and  dilated  pupils — give  the 
patient    the    appearance    of    death,    for 


which  catalepsy  is  said  to  have  been  mis- 
taken. 

Cutaneous  sensibility  is  often  abol- 
ished; in  some  cases  it  is  only  impaired; 
rarely  a  condition  of  hypersesthesia  has 
been  observed.  The  cornea,  conjunctiva, 
and  pharynx  may  present  no  evidence  of 
sensation,  or  they  may  retain  partial  sen- 
sibility; so  that  the  eyelids  will  close 
when  the  eyeball  is  touched,  and  the  re- 
flex of  the  pharynx  may  be  obtained.  In 
some  cases  the  power  of  deglutition  is 
said  to  have  been  lost,  but,  more  com- 
monly, when  the  food  is  placed  on  the 
posterior  portion  of  the  tongue  it  will  be 
swallowed.  The  deep  reflexes  are  usually 
lessened;  they  are  rarely  increased,  and 
in  some  cases  absent.  They  may  be 
present  on  one  side  and  absent  on  the 
other,  although  the  wax-like  condition, 
of  the  muscles  is  bilateral.  The  func- 
tions of  the  special  senses  seem  to  be  im- 
paired or  abolished,  although  in  some 
eases  it  is  possible  to  elicit  a  response 
from  the  patient  by  stimulating  the  or- 
gan of  hearing,  and  occasionally  that  of 
sight.  The  electrical  reactions  of  the 
muscles  and  nerves  have  been  found 
normal,  lessened,  and  in  exceptional 
cases  increased. 

The  paroxysms,  even  if  prolonged,  do 
not  remain  at  their  height  for  a  great 
length  of  time.  They  may  last  only  a 
few  minutes,  hours,  or  in  rare  cases 
days.  In  the  prolonged  attacks  there 
are  usually  intermissions  or  remissions, 
during  which  the  patient  completely  or 
partially  arouses  for  a  few  minutes  and 
then  relapses.  Hammond  says  the  par- 
oxysm generally  disappears  as  abruptly 
as  it  began.  "A  few  deep  inspirations 
are  taken,  the  eyes  are  opened,  or  lose 
their  fixedness,  the  muscles  relax,  and 
consciousness  is  restored,  but  no  knowl- 
edge of  what  has  occurred  is  retained." 
It  is  probable  that  in  the  majority  of 


692 


CATALEPSY.    COMPLICATIONS. 


cases  there  is  gradual  restoration  to  con- 
sciousness, the  patient  remaining  be- 
wildered and  stupid  and  the  muscles 
more  or  less  rigid  during  the  emergence 
from  the  cataleptic  state.  Eulenburg 
states  that  in  some  cases  the  attacks  may 
disappear  quite  suddenly.  "The  pa- 
tients recover  at  once  full  consciousness 
and  the  normal  use  of  their  muscles, 
take  up  their  employment  which  had 
been  interrupted,  continue  the  sentence 
previously  commenced,  and  conduct 
themselves  as  if  not  the  slightest  thing 
had  intervened." 

[I  have  seen  a  few  svieh  cases,  but  I 
have  looked  upon  them  as  epileptic  in 
character,  and  of  the  variety  known  as 
petit  mal.  The  subsequent  course  of 
two  of  these  has  shown  that  my  appre- 
hensions had  been  well  founded.     -J.  T. 

EsiiEIDGE.] 

Continuing,  Eulenburg  says:  "Much 
more  frequently  the  patient's  recovery 
is  only  slow  and  gradual;  they  are  at 
first  somewhat  stupid,  as  if  awakening 
from  an  unusually  sound  sleep.  Sensi- 
bility is  still  diminished,  the  power  of 
the  will  weakened;  a  certain  amount  of 
the  stiffness  of  the  muscles  still  remains 
for  some  time,  which  renders  motion  dif- 
ficult and  slow." 

The  frequency  of  paroxysms  varies 
greatly  in  different  cases.  One  or  more 
attacks  may  occur  in  the  twenty-four 
hours;  they  may  be  repeated  every  few 
days,  weeks,  or  months.  Just  as  we  find 
in  epilepsy,  so  we  not  infrequently  ob- 
serve in  catalepsy,  that  if  the  paroxysms 
return  every  few  weeks  or  months  several 
attacks  may  occur  at  these  times  within 
a  period  of  a  few  days.  In  rare  instances 
only  a  few  paroxysms  are  observed  dur- 
ing life-time,  separated  from  each  other 
by  a  period  of  years,  as  we  find  in  some 
cases  of  epilepsy.  In  still  more  excep- 
tional cases  only  one  attack  occurs. 

During    the    interval    of   the    attacks 


little  or  nothing  may  be  observed  to  dis- 
tinguish the  subject  from  a  normal  per- 
son. More  commonly,  especially  when 
the  paroxysms  occur  frequently  and  with 
any  regularity,  the  patient  is  irritable, 
nervous,  hysterical,  and  complains  of 
lassitude,  and  sometimes  of  dizziness  and 
headache,  during  the  interval  of  the 
attacks. 

Complications  and  Concomitant  Dis- 
orders.— The  complications,  or,  better, 
the  disordered  conditions  of  the  nervous 
system  which  the  phenomena  of  cata- 
lepsy may  complicate,  are  numerous. 

Hysteria  and  catalepsy  are  so  nearly 
alike  in  many  of  their  phases  that  it  is 
not  always  possible  to  draw  any  distinct 
line  between  the  two  affections.  The 
cases  complicated  by  hysteria  may  pre- 
sent one  of  the  following  conditions: 
All  the  phenomena  of  catalepsy  may  be 
present,  but  in  addition  thereto  therj 
may  be  numerous  and  pronounced  symp- 
toms of  hysteria,  both  during  the  attacks 
and  in  the  intervals;  or  the  seizures  may 
be  so  typically  hysterical  that  were  it 
not  for  the  symptoms  of  catalepsy  at  the 
time  of  the  paroxysms  the  case  would  be 
termed  one  of  pure  hysteria.  In  fact  it 
is  such,  with  the  phenomena  of  cata- 
lepsy added.  Such  cases  are  usually 
chronic,  little  influenced  by  treatment, 
and  the  patient  during  the  intervals  be- 
tween the  paroxysms  may  present  all 
kinds  of  hysterical  symptoms,  even  con- 
vulsions. 

What  has  been  said  in  regard  to  cata- 
lepsy complicated  by  hysteria  applies  in 
no  small  degree  when  this  affection  is 
associated  with  trance,  ecstacy,  somnam- 
bulism, and  certain  forms  of  somnolency. 
These  are  all  nearly  allied  to  hysteria 
when  they  are  due  to  a  functional  dis- 
turbance of  the  nervous  system. 

Catalepsy  often  occurs  in  association 
with   epilepsy,   chorea,   insanity,   or   or- 


CATALEPSY.     COMPLICATIONS. 


693 


ganic  diseases  of  the  brain.     In  chorea 
cataleptic    phenomena    have   been    met 
with,  and  in  some  instances  these  have 
been   quite   pronounced   with   states   of 
automatic     action     resembling     certain 
phases  met  with  in  hypnotism  especially 
in  children.    Epilepsy  may  be  associated 
with  cataleptic  symptoms,  but  we  should 
be  careful  in  the  study  of  these  cases  to 
determine  whether  the  latter  are  not  evi- 
dence of  true  epilepsy.    In  those  cases  of 
supposed  catalepsy  in  which  conscious- 
ness is  suddenly  recovered  and  the  pa- 
tient  immediately  returns   to   the   nor- 
mal condition,  finishes  the  employment 
which  had  been  begun  before  the  attack, 
or  continues  a  sentence  that  had  been 
interrupted,  and  acts  as  though  nothing 
had  happened,  it  is  quite  probable  that 
the  symptoms  are  epileptic  in  character. 
[Dr.    Thomas    King    Chambers    says: 
"Catalepsy  is  sometimes  very  brief  and 
sudden.    I  have  a  young  lady  now  under 
my  care,  for  non-assimilative  indigestion, 
of   whom   I   received   the   following   ac- 
counts from  a  mother  of  more  than  ordi- 
nary intelligence  and  power  of  observa- 
tion.    She  said  that  her  daughter  was 
fond  of  reading  aloud,  and  that   some- 
times in  the   middle   of  a  sentence   the 
voice  was  suddenlj'  stopped,  and  a  pecul- 
iar  stiffness   of  the   whole   body   would 
come  on  and  fi.x  the  limbs  immovably 
for  several  minutes.     Then  it  would  re- 
lax, and  the  reading  would  be  continued 
at  the  very  word  it  stopped  at,  the  pa- 
tient   being    quite    unconscious    that    a 
parenthesis  had  been  snipped  out  of  her 
sentence,  or  that  anything  strange  had 
happened.     She  grew  much  better  under 
tonic    and    restorative    treatment,    and 
gradually  ceased  to  have  these  singular 
attacks;     but    after    about    a    month's 
interval,  as  she  was  one  evening  engaged 
in  playing  a  round  game  of  cards,  she 
suddenly   went   off   into   a   regular   epi- 
leptic fit,  which  was  followed  by  sleep, 
and   she   did   not   recover   consciousness 
till  the  next  morning.    This  fit  could  be 
accounted  for  by  certain  errors  in  diges- 
tion, and  she  has  had  no  recurrence  of 


it,  or  of  the  catalepsy,  though  four 
months  have  passed  over.  So  I  hope  it 
was  epilepsy  of  an  intercurrent  or 
curable  sort."  One  feels  that  this  must 
have  been  a  vain  hope,  and,  had  the 
history  been  subsequently  continued  for 
a  period  of  a  year  or  more,  it  would 
probably  have  shown  that  the  case  was 
one  of  epilepsy,  and  not  of  the  "curable 
sort."  The  next  case  that  he  reports  is 
more  serious.  "But  sometimes  the  epi- 
lepsy preceded  by  catalepsy  is  of  a  more 
serious  sort.  I  remember  a  much-re- 
spected lecturer  in  this  metropolis  in 
whom  the  petit  mal  of  epilepsy  assumed 
this  form.  He  used  to  be  attacked  some- 
times in  the  middle  of  a  sentence,  with 
his  hand  wielded  in  demonstration  be- 
fore his  class.  He  would  remain  per- 
fectlj-  stiff  for  a  minute  or  so,  with 
mouth  open  and  arm  extended,  and  then 
resume  his  sentence  just  where  he  had 
dropped  it  quite  unconscious  that  any- 
thing had  happened.  After  a  time  the 
seizures  assumed  the  more  usual  and, 
more  fatal  form."  (Reynolds's  "Systerat 
of  Med."  [Hartshome],  vol.  i,  pp.  654- 
55).  I  have  seen  several  cases  of  epi- 
lepsy, especially  in  children,  the  first 
symptoms  of  which  simulated  those  of 
catalepsy.     J.  T.  Eskbidge.] 

Cataleptic  symptoms  in  eight  rachitics" 
aged  from  eighteen  months  to  three  and 
one-half  years.  The  phenomena  were 
manifested  by  the  persistence  of  the  posi- 
tion given  to  a  limb.  When  the  leg  was 
raised,  for  instance,  it  was  maintained 
in  this  position  for  a  long  time,  often  as 
long  as  fifteen  to  twenty  minutes,  in  one 
case  even  as  long  as  forty  minutes  and 
then  falling  very  slowly.  If  the  position 
of  the  limb  or  parts  of  it  was  changed, 
even  to  a  very  uncomfortable  attitude, 
the  immobility  would  be  maintained  for 
an  equal  period  of  time.  This  phenom- 
enon was  more  constant  and  distinct  in 
the  leg  than  in  the  arm.  There  was  no 
tremor  in  the  limb;  during  this  cata- 
leptic state  the  reflex  e.xcitability  seemed 
diminished.  Epstein  (Revue  Men.  des 
Mal.  de  I'Enfance,  Jan.,  '97). 

Insanity,  especially  stuporous  insanity, 
the  graver  forms  of  melancholia,  cata- 
tonia   (of   Kahlbaum),   and    paretic   de- 


694 


CATALEPSY.    DIAGNOSIS. 


nientia  may  be  associated  with  cataleptic 
conditions.  These  are  most  typically 
seen  and  most  frequently  met  with  in 
catatonia,  in  which  increased  motor  ten- 
sion is  one  of  the  diagnostic  symptoms 
of  the  disease.  In  the  other  forms  of  in- 
sanity the  cataleptic  phenomena  seem  to 
be  accidental.  Their  presence  in  any 
form  of  insanity  indicates  profound  nu- 
tritional changes,  and  therefore  adds 
gravity  to  the  prognosis.  Cases  of  or- 
ganic disease  of  the  hrain  only  infre- 
quently present  symptoms  somewhat 
similar  to  catalepsy.  Cases  of  tumor, 
abscess,  haemorrhage,  softening,  trau- 
matic injuries  of  the  brain,  and  of  men- 
ingitis, especially  of  the  tubercular  vari- 
ety, have  presented  temporary  symptoms 
of  catalepsy. 

It  is  important  to  bear  in  mind  that 
organic  disease  of  the  brain  may  be  the 
cause  of  cataleptic  phenomena,  lest  an 
organic  lesion  should  be  mistaken  for  an 
affection  that  is  functional  in  its  nature. 

Chloroform  or  ether  narcosis;  opium 
poisoning  in  extremely  rare  instances; 
and  certain  toxsemic  states,  probably 
from  autoinfection,  may  cause  conditions 
simulating  catalepsy.  It  is  so  rarely  that 
■one  meets  with  a  case  of  opium  poison- 
ing in  which  convulsions  or  cataleptic 
phenomena  are  present  that  were  the 
physician  not  on  his  guard  there  would 
be  great  danger  of  mistaking  the  case  for 
a  lesion  of  the  pons,  or  some  condition 
other  than  that  caused  by  a  lethal  dose 
of  opium. 

Hypnosis  and  catalepsy  need  no  dis- 
cussion here,  further  than  the  statement 
that  many  of  the  cases  of  catalepsy  re- 
ported as  occurring  in  very  young  chil- 
dren of  two  or  three  years  of  age  present 
symptoms  somewhat  similar  to  those 
seen  in  hypnotized  subjects,  especially 
in  those  in  which  the  hypnosis  has  been 
induced  by  the  Charcot  method,  such  as 


having  the  subject  stare  at  a  bright  ob- 
ject, held  in  such  a  position  as  to  cause 
the  eyes  to  converge  and  look  upward. 
Unilateral  cataleptic  phenomena  are 
often  seen  in  hypnotic  subjects.  It  may 
often  be  developed  at  the  will  of  the 
hypnotist. 

Diagnosis. — "The  peculiar  rigidity  of 
catalepsy  is  characteristic,  invariable, 
and  renders  the  diagnosis  a  simple  mat- 
ter," says  Gowers.  In  the  last  edition  of 
his  great  work  on  "Diseases  of  the  Nerv- 
ous System"  the  writer  states  that  "the 
diagnosis  of  catalepsy  presents  no  dif- 
ficulty." That  the  peculiar  rigidity  and 
wax-like  flexibility  must  be  present  be- 
fore we  are  justified  in  making  a  diag- 
nosis of  true  catalepsy,  I  think,  will  be 
accepted  by  almost  every  clinician,  but 
that  these  conditions  may  be  present  as 
prominent  symptoms  in  certain  grave 
diseases  of  the  central  nervous  system, 
and  possibly  mislead  the  physician  in 
mistaking  the  cataleptic  phenomena  for 
the  real  disease,  must  also  be  borne  in 
mind.  In  the  face  of  the  possibility  of 
the  occurrence  of  such  an  error,  it  seems 
to  me  that  it  is  the  first  duty  of  the  phy- 
sician in  the  diagnosis  of  catalepsy,  as  it 
is  in  hysteria,  to  determine  whether  the 
cataleptic  phenomena  are  caused  by  some 
organic  lesion.  The  same  principle  holds 
good  here  as  applied  to  hysteria.  The 
presence  of  numerous  symptoms  point- 
ing to  a  functional  affection  of  the  nerv- 
ous system  is  of  less  importance  in  the 
diagnosis  than  the  detection  of  one  posi- 
tive symptom  of  an  organic  lesion.  All 
cases  of  catalepsy  should  be  carefully 
studied  and  the  patient  systematically 
examined  lest  organic  disease  escape  de- 
tection. 

Trance,  somnambulism,  ecstasy,  or 
hysteria  in  its  ordinary  form  is  readily 
distinguished  from  catalepsy  on  account 
of  the  wax-like  flexibility  in  the  latter. 


CATALEPSY.    DIAGNOSIS. 


695 


Should  cataleptic  subjects  go  into  a 
trance,  or  an  hypnotic  state,  or  become 
ecstatic,  or  hysterical,  the  presence  of 
the  characteristic  symptoms  of  catalepsy 
would  probably  determine  the  diagnosis 
in  favor  of  the  latter  affection.  There 
might  be  danger  of  mistaking  a  case  of 
catatonia  for  catalepsy  were  one  not  on 
his  guard.  Of  the  former,  Spitzka  says: 
"The  most  striking  phenomena  of  the 
disorder  are  its  cataleptic  periods.  The 
catalepsy  is  typical  and  extreme.  For 
days,  weeks,  nay  months,  the  patients 
are  immobile,  resembling  sitting  corpses, 
requiring  to  be  fed  by  the  stomach- 
pump,  to  be  carried  to  and  from  their 
beds,  and  betraying  neither  by  look  nor 
word  that  they  have  any  mental  activity 
left." 

Case  of  a  patient  who  was,  on  one  oc- 
casion, placed  witli  one  foot  on  tlie 
ground  and  the  other  on  the  bench  be- 
hind him,  head  flexed  extremely,  one 
arm  raised  to  the  horizontal  position 
before  him  and  the  other  in  the  same 
position  behind  him.  The  patient  re- 
mained in  this  awkward,  and  what 
would  be  for  a  normal  person  impossible, 
position  for  an  hour  or  more  before  hia 
arms  began  gradually  to  descend.  In 
another  case  the  patient  retained  any 
possible  position  in  which  he  was  placed 
for  a  day  at  a  time.  The  history  of  the 
ease,  which  would  show  a  pathetical 
emotional  state,  with  a  tendency  to 
repetition  of  certain  words  and  phrases, 
together  with  the  prolonged  cataleptic 
periods  serve  to  determine  the  nature  of 
the  case.     Spitzka   ("Insanity"). 

There  is  little  danger  of  mistaking 
catalepsy  for  the  other  forms  of  insanity 
with  which  it  may  be  associated.  In 
hysteria  uncomplicated  with  the  cata- 
leptic phenomena,  the  local  position  of 
the  spasm  and  the  absence  of  the  wax- 
like condition  of  the  limbs  would  dis- 
tinguish it  from  catalepsy.  In  hysteria 
when  the  limbs  are  rigid  they  cannot 
be    flexed    without    using    considerable 


force.  The  peculiar  position  of  the 
hands  in  tetany  and  the  resistance  of- 
fered by  the  muscles  to  putting  the 
limbs  in  different  positions  would  pre- 
vent mistaking  this  affection  for  cata- 
lepsy. There  is  probably  no  danger  of 
confounding  catalepsy  for  epilepsy  if  the 
paroxysms  are  observed  by  a  person  of 
intelligence,  except  in  those  cases  of  the 
latter  disorder  in  which  the  initial  symp- 
toms closely  resemble  catalepsy.  A  sud- 
den return  to  consciousness  after  the 
exhibition  of  cataleptic  symptoms,  the 
patient  resuming  his  work  at  the  point 
at  which  it  had  been  left  off  or  con- 
tinuing a  sentence  from  the  word  at 
which  the  interruption  had  occurred, 
just  as  if  nothing  had  happened,  is 
strongly  suggestive  of  epilepsy. 

Catalepsy  may  be  feigned.  Of  course, 
it  is  an  easy  matter  for  a  person  to 
breathe  quietly,  and  allow  his  limbs  to 
be  placed  in  different  positions,  as  if 
they  were  made  of  soft  wax,  but  it  is 
not  possible  for  one  to  maintain  awk- 
ward and  uncomfortable  positions  for  a 
considerable  length  of  time  without  the 
breathing,  the  appearance  of  the  face, 
and  the  jerky  tremor  of  the  muscles 
showing  evidence  of  fatigue.  In  cata- 
lepsy if  a  weight  of  several  pounds  be 
attached  to  the  outstretched  arm  or 
slight  force  is  employed  to  depress  it, 
the  limb  will  gradually  descend  to  the 
side  of  the  body  without  the  person 
showing  any  evidence  of  effort  to  keep 
it  from  falling.  Simulators,  on  the  other 
hand,  invariably  endeavor  to  prevent  the 
limb  from  being  carried  down  by  force. 

Finally,  catalepsy  is  said  to  have  been 
mistaken  for  death.  The  waxy  flexibility 
of  the  limb  is  never  found  after  death. 
Anyone  who  has  employed  the  ophthal- 
moscope to  examine  the  optic  nerves 
after  death  can  never  mistake  the  ap- 


696 


CATALEPSY.    PROGNOSIS.    ETIOLOGY. 


pearance  of  these  and  the  whole  fundi. 
Everything  is  blanched  and  bloodless. 
In  the  absence  of  the  ophthalmoscope 
the  stethoscope  may  be  employed  to  de- 
tect the  heart's  action;  a  glass  mirror 
may  be  held  before  the  mouth  and  nos- 
trils to  determine  whether  the  patient  is 
breathing;  the  temperature  of  the  body 
may  be  taken,  but  this,  like  the  use  of 
electricity,  is  not  of  much  value  to  as- 
certain whether  the  patient  is  dead  or 
alive,  unless  some  hours  have  elapsed  to 
allow  the  temperature  of  the  body  to  fall 
and  electrical  changes  to  take  place.  Of 
tests  for  death,  immediately  after  its  oc- 
currence, there  is  none,  in  my  experi- 
ence, equal  to  the  use  of  the  ophthal- 
moscope. 

Prognosis. — Hammond  thinks  the  dis- 
ease does  not,  in  the  vast  majority  of 
cases,  tend  to  become  worse  either  in 
regard  to  severity  or  frequency  of  the 
paroxysms,  especially  in  those  cases  in 
which  the  exciting  causes  are  removed. 
Catalepsy  due  to  malaria  is  curable. 
When  the  affection  is  the  direct  result 
of  temporary  emotional  disturbance  and 
the  neurotic  element  of  the  subject  is 
not  too  profoimd,  a  cure  may  take  place. 
It  is  in  this  class  that  we  sometimes  meet 
with  only  one,  or  a  few,  attacks  during 
a  life-time.  Traumatism  to  the  head  or 
spine  may  give  rise  to  catalepsy  that 
may  be  only  temporary  in  character.  In 
the  majority  of  cases  catalepsy,  like  hys- 
teria, is  a  chronic  affection  and  may  last 
months,  years,  or  even  a  life-time,  with 
few  or  many  paroxysms,  depending  upon 
modifying  circumstances,  especially  edu- 
cation, the  morale  of  the  patient,  the  fre- 
quency, intensity,  and  character  of  the 
exciting  causes.  Catalepsy  is  probably 
never  the  direct  cause  of  death. 

Etiology. — The  causes  of  catalepsy  are 
predisposing  and  exciting.  The  consti- 
tutional neuropathic  condition  of  Grie- 


singer  is  the  favorable  soil  for  the  devel- 
opment of  numerous  neuroses,  such  as 
hysteria,  insanity,  epilepsy,  chorea,  and 
the  phenomena  of  catalepsy.  The  hys- 
terical neurosis  is  the  one  best  suited  for 
the  manifestation  of  the  cataleptic  phe- 
nomena. Congenital  preformations,  as 
Eulenburg  terms  them,  of  certain  por- 
tions of  the  central  nervous  system  pre- 
dispose to  catalepsy.  In  families  in 
which  in  one  or  more  members  hysteria 
or  catalepsy  has  developed,  other  nervous 
disorders — such  as  insanity,  epilepsy, 
chorea,  or  alcoholism — are  often  found. 
In  some  cases  epilepsy  precedes  the  man- 
ifestation of  cataleptic  phenomena;  in 
others  epilepsy  begins  with  symptoms  of 
a  cataleptoid  nature.  The  inheritance  of 
degenerative  tendencies  favor  develop- 
ment of  most  neuroses. 

Description  of  a  ease  studied  by  Dr. 
George  E.  de  Schweinltz  in  a  child,  fe- 
male, 2 '/.  years  old,  in  which  cataleptic 
phenomena,  with  a  condition  of  automa- 
tism very  similar  to  the  manifestations 
exhibited  by  some  hypnotized  subjects, 
were  witnessed  for  a  period  of  several 
weeks.  C.  K.  Mills  ("System  of  Med.," 
edited  by  Pepper,  vol.  v,  p.  316). 

Case  of  catalepsy  alternating  with 
violent  mental  excitement  in  a  married 
woman.  The  attacks  appeared  at  or 
about  the  menstrual  period.  During  one 
of  the  menstrual  periods  she  passed  a 
membranous  cyst  of  the  uterine  cavity 
and  complained  of  dysmenorrhoea  and 
menorrhagia.  Recovery  followed  treat- 
ment of  uterine  disorder.  Stone  (Lan- 
cet, Apr.  20,  1901). 

This  nervous  disorder  is  most  fre- 
quent at  puberty  and  from  that  period 
to  the  thirtieth  year.  A  number  of  cases 
have  been  observed  in  children.  Moti, 
referred  to  by  Mills,  records  eleven  cases 
met  with  in  children  from  the  fifth  to 
the  fifteenth  year,  the  average  being  nine 
years. 

Quite  well  marked  catalepsy  is  some- 
times observed  in  voung  children  of  one 


CATALEPSY.    ETIOLOGY. 


697 


or  two  years  ^¥hen  they  are  ill.    Prob- 
ably they  fall  into  a  sort  of  stupor;  or 
often  it  seems  that  they  are  rendered 
hypnotic,  as  it  were,  by  the  presence  of 
strangers.    Strumpel  ("Text-book  on  the 
Practice  of  Med.,"  p.  754,  Eng.  trans.). 
Women  are  more  likely  to  suffer  from 
catalepsy  than  men,  but  tlie  difference 
is  not  great.    Of  148  cases  collected  by 
Fuel,  80  occurred  in  females  and  68  in 
males.     Malnutrition,  caused  by  insuf- 
ficient or  improper  food,  or  conditions 
that  interfere  with  digestion  and  assimi- 
lation, favor  the  development  of  cata- 
lepsy.    Prostration  following  the  acute 
fevers  or  profound  mental  or  physical 
exhaustion  would  probably  not  give  rise 
to  the  disease  in  a  person  who  formerly 
had  a  healthy  and  normal  nervous  sys- 
tem;  but  in  a  neurotic  subject  such  a 
cause  might  greatly  enhance  the  predis- 
position, and  with  the  addition  of  any 
emotional  disturbance  it  would  probably 
be  sufficient  to  cause  the  development  of 
the  phenomena. 

Strong  and  suddenly-induced  emotion 
may  be  classed  among  the  first  of  the  ex- 
citing causes.  It  may  be  in  the  form  of 
moral  shock,  fright,  anger,  profound 
sorrow,  great  apprehension  of  evil,  in- 
tense mortification,  or  religious  excite- 
ment. 

The   emotion   is   in   the   form   of   de- 
pressing  moral    affections,    as    chagrin, 
hatred,   jealousy,    and    terror    at    bad 
treatment.     Puel  (Mills:  Pepper's  "Sys- 
tem of  Med.,"  vol.  V,  p.  318). 
It  is  evident  that  any  emotional  in- 
fluence that  is  great  enough  to  disar- 
range  suddenly   the    workings    of   the 
higher  nerve-centres  in  a  neurotic  sub- 
ject may  be  sufficient  to  produce  various 
emotional  manifestations,  among  which 
we  may  class  catalepsy. 

It  is  undoubtedly  true  that  prolonged, 
depressing  meditation  and  apprehension 
may  give  rise  to  the  disease.  The  appre- 
hension and  uncertainty  antedating  and 


attendant  upon  childbirth  may  favor 
the  development  of  the  nervous  state  or 
even  give  rise  to  it  if  the  labor  is  fol- 
lowed by  complications  or  depressing 
conditions. 

Case  following  the  second  confinement. 
Before  the  labor  the  woman  had  been 
very  nervous,  following  it  were  a  chill 
and  rather  high  fever  for  a  short  time, 
and  forty-eight  hours  later  catalepsy 
with  distinct  hysterical  symptoms  de- 
veloped. S.  S.  Cornell  ("Psychological 
Med.,"  Mann,  p.  470). 

Painful  menstruation,  pregnancy,  the 
parturient  state,  sudden  suppression  of 
menstruation,  dysmenorrhoea,  and  mas- 
turbation are  supposed  to  be  causes  of 
the  disorder.  Mills  refers  to  reflex  irri- 
tation as  an  exciting  cause,  and  instances 
a  case  of  preputial  irritation,  relieved  by 
circiimcision,  occurring  in  the  practice 
of  Dr.  James  Hendrie  Lloyd. 

Case  recorded  by  Austin,  in  his  work 
on    "General   Paralysis,"   in   which   the 
cataleptic  seizure  was  apparently  due  to 
ffecal    accumulations.     The    attack   dis- 
appeared promptly  after  the  bowel  had 
been   emptied   by   means   of   an  enema. 
Mills    (Pepper's  "System  of  Med.,"  vol. 
V,  p.  318). 
Traumatism,  such  as  blows  to  the  head 
or  spine,  may  give  rise  to  catalepsy.    Eu- 
lenburg  cites  a  case  seen  by  Jamieson  in 
which  a  blow  on  the  right  side  of  the 
back  was  followed  by  an  attack.    Peri- 
odic attacks  of  catalepsy  have  resulted 
from  malaria,  and  yielded  promptly  to 
antimalarial  treatment.  Hammond  men- 
tions one  case  in  which  worms  in  the 
intestinal  canal  were  the  apparent  cause. 
Gastro-intestinal  irritation  in  general  is 
a  frequent  cause  of  catalepsy  as  well  as 
of   hysteria.     Mills  mentions  the   fact 
that  catalepsy  may  occur  as  an  imitation 
of  epidemic  nervous  disturbance. 

Epidemic  of  icterus  in  children  associ- 
ated with  catalepsy;  the  children  al- 
lowed their  limbs  to  remain  motionless 
in     whatever     position     the     examiner 


698 


CATALEPSY.    ETIOLOGY. 


placed  them.  This  condition  persisted 
for  about  nine  days,  when  it  was  fol- 
lowed by  slow  improvement.  The  liver 
was  enlarged  in  all  cases,  but  were  not 
tender.  Cases  all  recovered.  O.  Damsch 
and  A.  Kramer  (Berliner  klin.  Woch., 
Mar.  21,  '98). 

Opium  and  ansesthetics  have  given  rise 
to  nervous  conditions  in  which  cataleptic 
phenomena  have  been  prominent.  Eu- 
lenburg,  in  discussing  theory  of  the  mus- 
cular condition  in  catalepsy,  says:  "The 
observation  often  made,  that  narcotics 
and  antesthetics,  at  a  certain  stage  of 
their  action,  before  the  production  of 
narcotism,  may  give  rise  to  slight  epi- 
leptic phenomena";  then  adds  in  a  foot- 
note: "I  have  myself  seen  an  exquisite 
case  of  flexiiilitas  cerea,  alternating  with 
trismus,  opisthotonos,  and  general  con- 
vulsions, in  a  patient  poisoned  by  mor- 
phia (by  0.09  gramme — 1  V3  grains — of 
the  hydrochlorate)"  ("Cyclopsedia  of  the 
Pract.  of  Med.,"  Ziemssen,  vol.  xiv,  p. 
379).  Eosenthal  refers  to  somewhat 
similar  results  following  the  adminstra- 
tion  of  anassthetics  and  poisonous  doses 
of  morphine. 

In  a  somewhat  ancient  American  med- 
ical periodical  (No.  Amer.  Med.  and 
Surg.  Jour.,  vol.  i,  p.  74,  '26)  Charles  D. 
Meigs,  of  Philadelphia,  gives  an  inter- 
esting accoi-mt  of  a  case  of  catalepsy 
produced  by  opium  in  a  man  27  years 
of  age.  The  man  had  taken  laudanum. 
His  arms,  when  in  a  stuporous  condi- 
tion, remained  in  any  posture  in  which 
they  happened  to  be  left;  his  head  was 
lifted  off  the  pillow  and  so  remained. 
"If  he  were  made  of  wax,"  says  Meigs, 
"he  could  not  more  steadily  preserve 
any  given  attitude."  The  patient  re- 
covered under  purging,  emetics,  and 
bleeding.  C.  K.  Mills  (Pepper's  "Sys- 
tem of  Med.,"  vol.  V,  p.  319). 

Darwin,  quoted  by  Meigs,  mentions 
a  case  of  catalepsy  which  occurred  after 
the  patient  had  taken  mercury.  He  re- 
covered in  a  few  weeks. 


[I  have  often  observed  a  rigid  condi- 
tion of  the  limbs  in  patients  while  tak- 
ing an  anesthetic.  It  is  a  frequent 
occurrence  under  such  circumstances, 
and  is  seen  just  before  the  stage  of 
narcosis  is  reached.     J.  T.  Eskridge.] 

It  is  important  to  bear  in  mind  that 
a  condition  simulating  catalepsy,  tris- 
mus, and  general  convulsions  may  occur 
from  lethal  doses  of  morphine.  Such 
phenomena  from  the  poisonous  effects 
of  opium  must  be  exceedingly  rare,  and 
are  probably  indirectly  due  to  the  pecul- 
iar nervous  organization  of  the  patient. 

Hypnosis,  induced  by  the  Charcot 
method,  such  as  having  the  subject  stare 
for  eight  or  ten  minutes  at  a  bright  ob- 
ject held  so  as  to  cause  the  eyes  to  look 
upward  in  convergence  is  often  attended 
by  cataleptic  phenomena:  the  so-called 
first  stage  of  hypnosis  of  Charcot.  I 
have  never  seen  this  condition  in  hyp- 
nosis induced  by  the  Nancy,  or  suggest- 
ive, method,  provided  no  suggestions 
were  made  to  develop  muscular  rigidity. 

Catalepsy  occasionally  occurs  in  asso- 
ciation with  insanity.  It  has  been  met 
with  in  connection  with  mania,  melan- 
cholia, and  paralysis  of  the  insane. 
When  it  is  observed  among  the  insane 
it  is  most  commonly  found  in  the  graver 
forms  of  melancholia,  and  in  profound 
conditions  of  stupor.  The  mental  con- 
dition under  such  circumstances  is  the 
cause  of  the  cataleptic  phenomena.  One 
form  of  insanity,  catatonia,  first  de- 
scribed by  Kahlbaum,  of  Gorlitz,  about 
twenty-three  years  ago,  is  always  in  its 
typical  form  attended  by  motor  tension 
sufficiently  marked  to  maintain  the 
limbs  in  whatever  position  they  may  be 
placed  for  hours,  or  even  a  day  or  more, 
if  we  may  accept  the  statements  of  Kahl- 
baum and  Spitzka. 

Finally,  numerous  organic  diseases  of 
the  brain  are  sufficiently  often  attended 
with   cataleptic  phenomena  to   demon- 


CATALEPSY.    PATHOLOGY. 


699 


strate  a  causative  relationship  between 
the  organic  cerebral  lesion  and  the  mani- 
festation of  the  motor  tension.  These 
phenomena  have  been  seen  more  com- 
monly as  transient  symptoms  in  tumor, 
abscess,  hagmorrhage,  and  softening  of 
the  brain,  and  in  meningitis.  It  is  a 
common  experience  to  find  a  cataleptoid 
condition  suddenly  develop  in  cases  of 
organic  disease  of  the  brain.  It  is  prob- 
able that  partial  cataleptic  states  of  the 
muscles  would  be  detected  more  fre- 
quently than  they  are  were  physicians 
to  examine  for  them  in  every  case  of 
brain  disease  coming  under  their  obser- 
vation. 

Conclusions  after  a  study  of  fifteen 
cases:  Cataleptic  states  which  develop 
in  the  course  of  psychoses  are  often 
slight,  brief,  and  partial.  With  increase 
of  muscle-tension  and  enfeeblement  of 
voluntary  psychomotor  activity  they  are 
often  due  to  enfeeblement  of  perception 
of  fatigue  and  to  the  persistence  of  com- 
municated motor  images;  they  may  de- 
velop in  a  number  of  mental  maladies, 
especially  in  alcoholic  delirium,  melan- 
choly, mental  confusion,  manias,  peri- 
odic insanity,  the  delirium  of  degen- 
erates, and  in  congenital  or  acquired 
mental  feebleness;  they  may  precede  or 
follow  an  epileptic  crisis;  hysteria  is 
rarely  connected  with  them;  there  is 
no  catatonia  of  Kahlbaum;  and  these 
states  are  easily  simulated.  Paul  le 
Maitre  ("Contributions  a  I'Etude  des 
Etats  Cataleptiques  dans  les  Maladies 
Mentales,"  p.  96,  '95). 

Pathology. — The  examinations  of  the 
bodies  of  some  cataleptic  subjects,  who 
during  life  presented  undoubted  evi- 
dences of  organic  disease  of  the  brain, 
have  revealed  certain  gross  lesions  of  the 
central  nervous  system,  especially  of  the 
brain.  These  findings  prove  nothing  in 
regard  to  the  pathological  anatomy  of 
catalepsy,  because  the  autopsies,  held  on 
the  bodies  of  persons  who  during  life 
presented    distinct    symptoms    of    cata- 


lepsy without  evidence  of  organic  brain 
disease,  have  been  attended  with  abso- 
lutely negative  results.  We  are,  indeed, 
in  absolute  ignorance  of  the  pathogene- 
sis of  catalepsy. 

In  regard  to  the  theory  of  muscular 
rigidity  and  the  wax-like  flexibility  of 
the  limbs,  observed  as  the  most  signifi- 
cant symptom  of  the  phenomena  of  cata- 
lepsy, speculation  has  been  rife.  In  the 
present  state  of  our  ignorance  concern- 
ing the  intimate  nature  of  the  subject, 
the  most  elaborate  theories  are  only 
speculations. 

In  the  normal  condition  the  constant 
muscular  tonus  seems  to  be  sufficient  to 
adapt  the  muscles  for  lengthening  and 
shortening  without  any  disturbance  of 
the  harmony  of  action  between  the 
synergic  and  antergic  groups  of  muscles 
concerned  in  extending  and  flexing  the 
limbs.  The  nervous  reflex  concerned  in 
maintaining  the  nicely-adaptable  mus- 
cular tonus  is  composed  of  the  muscle- 
nerves  and  the  motor  cells  of  the  spinal 
cord.  We  have  every  reason  for  believ- 
ing that  the  higher  nerve-centres  con- 
trol, probably  by  inhibition,  the  lower 
ones;  and  that  in  case  the  inhibitory 
power  of  the  higher  centres  over  the 
lower  is  impaired  or  lost,  the  latter  cen- 
tres may  run  riot  and  cause  exagger- 
ated muscular  tonus.  In  catalepsy  the 
highest  nerve-centres  seem  to  lose  their 
inhibitory  power  over  the  lower;  and 
hence  we  find  an  increase  of  the  mus- 
cular tonus.  Did  we  not  have  to  go 
further  and  explain  certain  other  phe- 
nomena observed  in  catalepsy  we  should 
have  little  difficulty  in  accepting  the 
theory  that  impairment  or  loss  of  the 
inhibitory  power  of  the  higher  nerve- 
centres  is  the  direct  mechanism  by  which 
this  afliection  is  produced.  In  other  and 
widely  different  conditions  from  the  one 
under  consideration,  in  which  we  know 


700 


CATALEPSY.    TREATMENT. 


that  the  communication  between  the 
higher  and  lower  nerve-centres  is  made 
ditiicult  or  entirely  impossible,  as  wit- 
nessed in  lesions  in  the  upper  portion  of 
the  cord  and  in  the  motor  regions  of 
the  brain,  the  muscular  tonus  is  not  only 
increased,  but  the  deep  reflexes  are  also 
increased  and  the  typical  wax-like  condi- 
tion of  the  muscles,  as  observed  in  cata- 
lepsy, is  rarely  seen.  In  catalepsy,  on 
the  other  hand,  while  the  muscular  tonus 
is  increased,  the  deep  reflexes  are  dimin- 
ished. It  is  a  curious  fact  that  compara- 
tively mild  passive  motion  will  cause  the 
limbs  to  mold  themselves  in  various 
positions  in  catalepsy;  yet  a  far  greater 
stimulant  to  muscles,  muscle-nerves,  and 
cutaneous  nerves — the  strongest  faradic 
or  galvanic  current — fails  to  accomplish 
the  same  result. 

[This  does  not  seem  to  me  so  difHcult 
of  explanation  as  Eulenburg  seems  to 
infer.  By  passive  motion  the  limbs  are 
not  made,  even  in  catalepsy,  to  assume 
different  positions  on  account  of  any 
stimulation,  either  direct  or  indirect, 
communicated  to  any  reflex  nervous  ap- 
paratus, but  the  change  in  position  of 
the  limb  is  the  result  of  mechanical 
force,  applied  usuallj'  to  the  best  ad- 
vantage to  accomplish  the  desired  re- 
sult. On  the  other  hand,  when  elec- 
tricity is  applied  to  a  group  of  muscles 
to  cause  flexion  or  extension  of  a  limb, 
the  power  does  not  act  to  the  same  ad- 
vantage to  cause  the  limb  to  assume 
different  positions  as  is  the  case  when 
passive  motion  is  employed;  besides  in 
the  use  of  strong  currents  of  electricity 
diffusion  of  the  currents  to  a  greater 
or  less  extent  takes  place,  and  in  eon- 
sequence,  indirect  stimulation  of  the  an- 
tagonistic group  of  muscles  results.     J. 

T.    ESKEIDGE.] 

Eosenthal  thinks  the  waxy  mobility  is 
due  to  reflex  contraction.  Eulenburg, 
in  commenting  on  this  conclusion, 
states:  "To  the  latter  view  we  are  at  all 
events  driven;   but  just  the  'how?'  and 


the  'wherefore?'  of  the  form  or  reflex 
action  is,  alas!    still  unknown  to  us." 

At  the  present  day  it  is  impossible  to 
account  for  all  the  phenomena  that  oc- 
cur in  catalepsy.  That  it  is  a  symptom 
of  a  disordered  condition  of  the  highest 
nerve-centres,  the  cerebral  cortex,  seems 
to  be  a  fact.  That  during  the  attacks, 
the  nervous  system,  especially  the  spinal 
representatives  of  it,  is  in  an  excitable 
state,  with  a  disarrangement  of  the  nor- 
mally-adj  listed  influence  of  the  higher 
nerve-centres  over  the  lower  appears  to 
be  equally  true.  When  the  pathology 
of  hysteria  is  thoroughly  understood 
then  we  shall  be  able  to  explain  many, 
if  not  all,  of  the  manifestations  observed 
in  catalepsy.  Until  then  we  may  observe 
and  gather  facts  to  be  utilized. 

[No   one  in  discussing  the  theory  of 

the  mechanism  of  the  phenomena  that 

occur  in  catalepsy  has  apparently  taken 

into    account   the   possible   influence    of 

suggestion.  '  J.   T.   Eskridge.] 

Treatment. — This   should    consist    of 

measures  for  the  relief  of  the  paroxysm, 

and  the  employment  between  the  attacks 

of  those  agents  most  likely  to   aid   in 

toning  up  the  nervous  system,  together 

with  such  changes  in  the  daily  life  and 

surroimdings  of  the  patient  as  are  best 

adapted  to  improve  the  mental  state. 

Two  cases  showing  the  beneficial 
effects  of  thyroid  medication  after  the 
complete  failure  of  other  methods  of 
treatment. 

Conclusions:  1.  That  in  conditions 
marked  by  inhibition  of  sensory,  motor, 
and  mental  activity,  without  gross  or- 
ganic lesion,  such  as  are  met  with  in 
catatonia  and  in  certain  types  of  stu- 
porous insanity  and  melancholia,  we 
may  expect  benefit  from  thyroid  medi- 
cation, judiciously  used. 

2.  That  the  effects  of  thyroids  in  full 
dose  bear  a  striking  resemblance  to 
many  of  the  symptoms  of  Graves's  dis- 
ease, namely:  orbicular  weakness,  con- 
secutively conjunctivitis,  skin  eruptions, 
and  temporary  bronzing,  without  icterus 


CATALEPSY.    TREATMENT. 


701 


of  the  eyes,  profuse  local  foetid  sweats, 
subjective  sense  of  heat  and  thirst,  ex- 
cessive metabolism,  decided  tachycardia, 
and  the  absence  of  any  fixed  relation 
between  pulse-rate,  respiration  and  tem- 
perature. Joseph  G.  Rogers  (Amer. 
Jour,  of  Insanity,  July,  '97). 

During  the  paroxysm  it  is  always  well 
to  unload  the  bowel  with  a  high  enema, 
consisting  of  about  3  pints  to  2  quarts  of 
warm  water  to  which  1  or  2  ounces  of 
the  tincture  of  asafoetida  have  been 
added.  After  the  bowels  have  been  thor- 
oughly opened  in  the  manner  indicated, 
Vz  ounce  of  the  tincture  of  asafoetida  in 
about  4  ounces  of  water  may  be  thrown 
into  the  bowel  high  up  and  allowed  to 
remain.  If  the  attack  is  severe  15  or 
20  grains  of  chloral-hydrate  may  be 
added  to  the  tincture  of  asafoetida  for 
the  small  enema,  in  which  case  milk 
should  be  used  instead  of  water.  If  the 
stomach  contains  any  undigested  food 
Vie  grain  of  apomorphine  may  be  given 
hypodermically.  A  free  emesis  even 
when  there  is  no  undigested  food  in  the 
stomach  may  aid  in  aborting  the  par- 
oxysm. 

To  shorten  the  attack  inhalations  of 
amyl-nitrite  or  an  hypodermic  of  ^/i„o 
grain  of  nitroglycerin  may  be  employed 
with  advantage.  Cool  applications  to 
the  head  and  passing  a  piece  of  ice  up 
and  down  the  spine  several  times  and 
following  this  by  briskly  rubbing  the 
spine  with  a  coarse  towel  greatly  aid  in 
establishing  reaction.  A  mustard  plaster 
to  the  nape  of  the  neck  and  one  over  the 
stomach  have  the  same  effect.  DiflFusible 
stimulants,  especially  ammonia,  may  be 
used  with  advantage. 


During  the  intervals  the  treatment 
and  general  management  are  of  consid- 
erable importance,  and  should  receive  as 
much  attention  as  in  a  case  of  hysteria. 
In  the  first  place  careful  attention  should 
be  paid  to  the  food  and  organs  of  diges- 
tion. The  diet  should  be  nutritious, 
easily  digested,  and  abundant.  If  neces- 
sary, digestion  may  be  aided  by  the  ordi- 
nary means.  A  free  action  of  the  bowels 
should  be  obtained  each  day.  Iron, 
arsenic,  quinine,  and  strychnine  should 
be  employed  in  the  building-up  process. 

Systematic,  but  not  violent  or  over- 
fatiguing,  exercise  should  be  insisted 
upon  for  all  those  who  are  not  too  weak. 
A  little  gymnasium  can  be  arranged  in 
most  bed-rooms,  and  the  beneficial  re- 
sults to  be  derived  from  regular  exercise 
for  a  few  minutes  night  and  morning 
can  scarcely  be  estimated  until  after  one 
has  tried  it.  A  cool  or  cold  sponge-  or 
plunge-  bath  should  be  indulged  in  night 
and  morning,  following  the  exercise.  At 
the  same  time  the  patient  should  be  kept 
in  the  open  air  as  much  possible. 

If  the  patient  is  a  child  or  young  adult 
the  education  should  be  judiciously  su- 
pervised, and  all  oversentimental  and 
emotional  books  excluded.  Companion- 
ship for  such  patients,  be  they  children 
or  adults,  is  of  great  importance.  In 
short,  everything  in  reason  that  tends 
to  develop  muscle  and  improve  the  men- 
tal and  physical  condition  of  the  patient 
should  be  encouraged,  while  exhaustion, 
depressing  agents,  poor  nutrition,  and 
emotional  excitement  should  be  avoided 
if  possible. 

J.  T.  ESKRIDGE, 

Denver. 


4i>'\j:., 


